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CQPXRIGHT DEPOSIT. 



DISEASES OF CHILDREN 



A TEXT-BOOK FOR THE USE OF 
STUDENTS AND PRACTITIONERS OF MEDICINE 



BY 



C. SIGMUND RAUE, M. D., 

PROFESSOR OF PEDIATRICS, HAHNEMANN MEDICAL COLLEGE, OF PHILADELPHIA; VISITING PEDIATRIST 

TO THE HAHNEMANN HOSPITAL, PHILADELPHIA; CONSULTING PHYSICIAN TO THE 

CHILDREN'S HOMEOPATHIC HOSPITAL, PHILADELPHIA, ETC. 



THIRD EDITION, REWRITTEN 



PHILADELPHIA: 

BOERICKE & TAFEL. 

1922. 






COPYRIGHTED 
BY 

BOERICKE & TAFEL 



JUL 22 1922 



'CI.A677609 



PREFACE TO THE THIRD EDITION 



The present work, while based upon the previous editions of 
the author's Diseases of Children, has been entirely re-written. 
The bulk of the material is, therefore, new; this applies particu- 
larly to the chapters on infant feeding, diseases of the digestive 
tract, infantile diarrheas and constitutional diseases. It has 
also been necessary to add a number of new articles, for example 
— lethargic encephalitis, myatonia congenita, spasmophilia, the 
exudative diathesis and acidosis. On the other hand, some 
topics which were discussed in the former edition are omitted as 
they were of purely surgical interest. Illustrations have also 
been omitted in an effort to keep down the bulk of the book. 
The author feels that they are not essential to a work of this size 
and scope. 

The prime objective of the writer has been to present to 
the profession a work which will answer the purposes of a text- 
book for students and a reference book for the busy practitioner. 
He has, therefore, endeavored to give not only a concise descrip- 
tion of the diseases of children but also full instructions in the 
care aud feeding of infants and children and in the treatment 
of the diseases under discussion. 

The homeopathic treatment of the diseases of children is 
fully discussed and is based upon the author's many years of 
experience in this field. The indications for the selection of 
the homeopathic remedy as well as the dosage and method of 
administration are presented in such a manner that physicians 



IV PREFACE 

who have not had special training in homeopathic materia 
medica but who desire to use homeopathic treatment in their 
practice can get the information and help they are seeking. 
The chapters on Homeopathic Therapeutics and Homeopathic 
Prescribing in Diseases of Children have been especially 
written with this point in mind. The author desires to say, 
however, that he has felt free to discuss and present all methods 
of treatment which are generally accepted as possessing specific 
clinical value irrespective of their mode of action and wher- 
ever their use is advisable or is imperative, he has unequivocally 
recommended them. 

Philadelphia, June, 1922. 



PREFACE TO THE SECOND EDITION 



Since the appearance of the first edition of this work a num- 
ber of important discoveries have been made in the field of 
Pediatrics, and some significant changes have occurred in the 
views held at that time regarding the etiology and treatment of 
not a few of the commonest affections in childhood. Further- 
more, it is but fair to say that the writer himself has felt the 
need for revising some of his views expressed in the former 
edition, for with riper years and larger experience he has 
learned the value of conservative methods, and has endeavored 
to replace the mere possibilities of therapeutics with clinical 
certainties. 

The text has been entirely rewritten, and new matter has 
been added wherever it was found desirable to amplify any 
subject. The chapter upon Infant Feeding is practically new, 
and the aim has been to present in a concise and clear form the 
most acceptable and modern views upon this subject, which has 
of late years been made unnecessarily complicated. A chapter 
upon Diseases of the Ear, 'Nose and Throat has been added, 
and illustrations have been inserted wherever a picture or a 
diagram could be advantageously employed to elucidate the text. 

I am again indebted to a number of my colleagues for 
valuable suggestions and friendly co-operation, which, to my 
mind, is necessary in any work covering so broad a field as 
that of Pediatrics. Dr. Chas. M. Thomas has kindly read the 
sections dealing with the diseases affecting the eyes, the ears, 



VI PREFACE 

the nose and the throat, and has made a few additions to the 
manuscript. To Dr. Wm, B. Van Lennep I am indebted for 
assistance in revising the articles upon appendicitis and intus- 
susception, and also for suggestions concerning the treatment 
of other conditions, wherever this has presented a surgical 
aspect. Dr. W. D. Bayley has kindly offered some suggestions 
relative to Mental and Nervous Diseases. 

For the excellent index I am indebted to Dr. Ernest A. Far- 
rington, whose painstaking arrangement of the various sub- 
jects mentioned and discussed must of necessity add to the 
practical value of the book. I have also to thank the pub- 
lishers for their liberality in preparing the many illustrations, 
and for numerous other courtesies. 

I cannot refrain from expressing my appreciation of the 
kind reception which the first edition received at the hands of 
the profession and of the students of our colleges, and while 
my aim has been not to overstep the bounds of a Text-Book, I 
trust that the busy practitioner will find within these pages 
all the practical information which he may need. 

February, 1906. 



PREFACE TO THE FIRST EDITION 



In presenting this work to the profession the author has 
aimed to make it a purely clinical one. 

In the sections on treatment he has endeavored to give his 
own experience as much as possible, and has sought to exclude 
all doubtful symptoms and theoretical indications. 

The section on Skin Diseases is from the pen of Dr. Leon 
T. Ashcraft, Lecturer on Venereal Diseases at the Hahnemann 
College. 

In the section on Nervous Diseases, valuable suggestions 
have been made by Dr. Weston D. Bayley, Lecturer on Mental 
Diseases and Clinical Instructor in Nervous Diseases at the 
Hahnemann College. 

Philadelphia j 1899. 



TABLE OF CONTENTS 



CHAPTEE I. 

Hygiene and Nursing. 

The New-born — Bathing — Clothing — The Mouth and Teeth — Sleep — 
The Bowels — Airing — Exercise — Premature and Delicate Infants — 
The Care and Nursing of Sick Children — Temperature in the Sick 
Eoom — Clothing in Sickness — Heat — Baths — Packs — Inhalation — 
Lavage — Irrigation of the Colon and Enemata 1 

CHAPTER II. 

Methods of Clinical Examination. 

The Period of Infancy and Childhood — Mortality — The History — Phys- 
ical Examination — Palpation — Percussion — Auscultation — Pulse 
Temperature, Eespiration — The Urine 10 

CHAPTEE III. 

Therapeutics. 
Homeopathy — Dosage — Prescribing in Diseases of Children 24 

CHAPTEE IV. 

Infant Feeding. 

Anatomy and Physiology of the Digestive Tract — The Stools — Factors 
Influencing the Character of the Stools — Abnormal Constituents in 
the Stools — Maternal Nursing — Indications for Mixed Feeding — 
Indications for Weaning — The Wet-nurse — Metabolism in In- 
fancy — Protein Metabolism — Fat Metabolism — Carbohydrate Met- 
abolism — The Mineral Salts in Metabolism — Artificial Feeding — 
Caloric Eequirements in Infancy — Calorie Eequirements and 
Weights According to Age — The Digestibility of Cow's Milk — The 
Proteins of Cow's milk— The Fat of Cow's Milk— The Carbohy- 
drate of Milk— The Quantity of Food Eequired— Top-Milk Dilu- 
tions — Method of Calculating the Ingredients in the Food — Method 
of Estimating Percentages in a Milk Formula — Method of Esti- 
mating the Number of Calories in a Milk Formula — The Use of 
Lime Water and Other Alkalies — Pasteurization; Boiled Milk — 
The Preparation of the Food — Feeding During the Second Year — 



X CONTENTS 

Diet for a Child 1 Year to 18 Months— Diet for a Child 18 Months 
to 2 Years — Diet for a Child 3 Years and Over — Forbidden 
Foods — Special Foods and Proprietary Foods 34 

CHAPTER V. 

Diseases of the Newborn. 

Congenital Defects — Asphyxia — Cephalhematoma — Hematoma of the 
Sterno-mastoid Muscle — Intracranial Hemorrhages — Septic and 
Other Infections in the New-born — Erysipelas — Tetanus — Gonor- 
rhea — Ophthalmia Neonatorum — Acute Fatty Degeneration, or 
Buhl's Disease — Acute Hemoglobinuria, or Winkel's Disease — 
Mastitis — Vaginal Hemorrhage — Icterus Neonatorum — Hemor- 
rhagic Disease of the New-born — Sudden Death in Infants 83 

CHAPTER VI. 

Diseases of the Mouth. 

Dentition — Abnormalities of the Teeth — Stomatitis — Catarrhal Stoma- 
titis — Pityriasis Linguae — Aphthous Stomatitis — Bednar's Aph- 
thae — Aphthae Epizooticae — Ulcerative Stomatitis; Putrid Sore 
Mouth — Parasitic Stomatitis; Thrush — Gangrenous Stomatitis — 
Noma — Treatment of Stomatitis 95 

CHAPTER VII. 

Diseases of the Gastrointestinal Tract. 

Introductory — Vomiting — Acute Gastric Indigestion; Dyspepsia — 
Chronic Indigestion — Coeliae Disease — Mucous Colitis — Infan- 
tilism — Hirschsprung's Disease — Acidosis — Cyclic, or Recurrent 
Vomiting — Hypertrophic Pyloric Stenosis — Diarrhea — Dyspeptic 
Diarrhea; Acute Intestinal Indigestion — Infectious Diarrhea — 
Cholera Infantum — Acute Ileocolitis; Dysentery — Membranous 
Colitis — Special Symptoms and Their Management — Remedies — 
Constipation — Intussusception — Appendicitis — Intestinal Para- 
sites — Morphology — Ascaris Lumbricoides — Tenia Saginata — 
Tenia Solium 104 

CHAPTER VIII. 

Diseases of the Peritoneum. 
Acute Peritonitis — Chronic Peritonitis; Tuberculous Peritonitis 161 

CHAPTER IX. 

Diseases of the Respiratory Tract. 

Spasm of the Glottis — Acute Catarrhal Laryngitis; Spasmodic Croup — 
Acute Bronchitis — Chronic Bronchitis — Bronchial Asthma — Acute 



CONTEXTS XI 

Bronchopneumonia — Croupous Pneumonia — Cerebral Pneumonia — 
Wandering Pneumonia — Central Pneumonia — Pneumonia with Gas- 
trointestinal Symptoms — Influenzal Pneumonia — Abortive Pneu- 
monia — Typhoid-Pneumonia — Pleuro-Pneumonia — Complications — 
Physical Signs — Pulmonary Tuberculosis — Acute Miliary Tuber- 
culosis — Tuberculous Bronchopneumonia — Chronic Pulmonary 
Tuberculosis — Special Symptoms — Emphysema 165 

CHAPTEE X. 

Diseases of the Heart and its Membranes. 

Introductory — Congenital Diseases and Deformities — Pericarditis — En- 
docarditis; Valvular Heart Disease — Myocarditis 219 

CHAPTER XL 

Diseases of the Kidneys and Urinary Tract. 

Introductory — Albuminuria — Postural Albuminuria; Lordotic Album- 
inuria — Edema Without Kidney Lesion — Hematuria; Hemoglob- 
inuria — Acute Nephritis — Chronic Nephritis; Bright 's Disease — 
Chronic Parenchymatous Nephritis — Chronic Interstitial Nephri- 
tis — Diabetes Insipidus — Diabetes Mellitus — Pyelitis — Enuresis — 
Vulvovaginitis ; Gonorrhea 242 

CHAPTER XII. 

Diseases of the Skin. 

Introductory — Miliaria; Prickly heat — Eczema — Erythema Scarlati- 
noides — Furunculosis ; Boils — Impetigo Contagioso — Urticaria ; 
Hives — Vegetable Parasitic Diseases; Tinea — Tinea Tonsurans; 
Ringworm of the scalp — Tinea Circinata; Ringworm — Animal 
Parasites — Scabies; Itch 268 

CHAPTER XIII. 
Diseases of the Blood. 
Introductory — Anemia — Chlorosis — Progressive Pernicious Anemia — 
Leukemia; Pseudo-Leukemia; Splenic Anemia; Hodgkin's Dis- 
ease — Anemia Infantum Pseudoleukemia Von Jaksch — Hemo- 
philia — Purpura 285 

CHAPTER XIV. 

Diseases of the Nervous System. 
Introductory — Psychoses — Idiocy and Mental Deficiency — Mongolian 
Idiocy — Sporadic Cretinism — Meningitis — Epidemic Cerebrospinal 
Meningitis; . Spotted Fever — Tuberculous Meningitis — Lumbar 
Puncture — Lethargic, or Epidemic Encephalitis — Hydrocephalus — 
Convulsive Affections — Epilepsy — Chorea — Spasmus Nutans ; Head- 



Xll CONTENTS 

nodding with Nystagmus — Neuropathic Constitution and Hys- 
teria — Paralytic Affections; Cerebral Palsies — Little's Disease — 
Acute Poliomyelitis, or Infantile Paralysis — Progressive Muscular 
Atrophy — Pseudo -hypertrophic Paralysis — Family Ataxia — Syrin- 
gomyelia — Multiple Cerebro-spinal Sclerosis — Myatonia Congen- 
ita — Multiple Neuritis — Headache 304 

CHAPTER XV. 

Diseases of the Ear, Nose and Throat. 
Introductory — < Otitis — Earache — Discharge — Tuberculosis — Influenza 
— Acute Catarrhal and Acute Purulent Otitis Media — Acute Ton- 
sillitis — Acute Superficial Tonsillitis — Acute Follicular Tonsillitis 
— Vincent's Angina — Acute Parenchymatous Tonsillitis; Periton- 
sillar Abscess — Hypertrophy of the Tonsils — Eetro-pharyngeal 
Abscess — Acute Rhinitis; Pseudo-Membranous Rhinitis — Simple 
Chronic Rhinitis — Purulent Rhinitis — Hypertrophic Rhinitis; Atro- 
phic Rhinitis — Treatment of Chronic Rhinitis — Adenoid Vegeta- 
tions of the Naso-pharynx 393 

CHAPTER XVI. 

Diathetic and Constitutional Diseases. 

Marasmus, or Athrepsia; Malnutrition — Rickets; Rachitis — Fetal Rick- 
ets — Infantile Scurvy; Barlow's Disease — Exudative Diathesis — 
Spasmophilia; Tetany — General Convulsions; Infantile Eclampsia 
— Status Lymphaticus and Enlargement of the Thymus Gland — 
Tuberculosis — Scrofula — Tuberculous Adenitis — Hereditary Syph- 
ilis — Rheumatism 422 

CHAPTER XVII. 

Acute Infectious Diseases. 
Exanthemata — Measles, Rubeola — Scarlet Fever — Rubella — Rubella 
Scarlatinif orme — Diphtheria — Klebs-Loeffler Bacillus — Diphther- 
itic Paralysis — Septic Diphtheria — Primary Laryngeal Diphtheria — 
Pseudo -Diphtheria — The Shick Test — Serum Therapy — Glandular 
Fever — Typhoid Fever — Abortive Type — Reinfection and Relap- 
ses ; Recurrences — Meningitis — Variola ; Varioloid — Vaccinia — 
Varicella — Varicella Gangrenosa — Pertussis — Parotitis — Second- 
ary Parotitis — Influenza — Bacillus of Pfeiffer — Malaria; Malarial 
Fever — Masked or Irregular Forms of Malaria and Malarial 
Cachexia 471 



Diseases of Children. 



CHAPTER I. 



HYGIENE AND NURSING. 



The New-born. — The first step in the care of the new-born 
infant, after respiration has been established, is the care of the 
eyes. They should be thoroughly cleansed with a warm, sat- 
urated solution of boric acid, after which a drop of a 2 per 
cent solution of nitrate of silver is dropped into each eye 
according to the method of Crede. By carrying out this 
prophylactic measure ophthalmia neonatorum can in most 
instances be prevented. 

After the cord has been dusted with powdered boric acid and 
dressed in sterilized gauze the child should be wiped dry, the 
body anointed with sweet oil, especially when there is an 
abundance of vernix caseosa, then wrapped in a warm blanket 
and laid aside until it is convenient to give it the cleansing 
bath. Asepsis in the care of the cord is of the greatest impor- 
tance since the majority of cases of septic infection in the 
new-born originate at this site. The early dropping of the cord 
is favored by the use of dry dressings; salves and ointments 
should not be used. The stump must be carefully dressed until 
healed. 

Bathing. — The full bath should not be given until the cord 
has fallen off. This usually occurs at the end of the first week. 
The child should be bathed in a warm room, preferably before 
an open fireplace. The first bath must be a warm one, approx- 
imating the normal body temperature; in hardy children it 



2 DISEASES OF CHILDREN 

can gradually be reduced, so that a temperature of 95 degrees 
F. may be reached, by the end of the sixth month. It should 
be of short duration and the body dried by light rubbing with 
a soft towel. The bath is best given in the morning before 
the second nursing. In children who do not react well the full 
bath may have to be discontinued and a sponge bath used instead. 
The use of too much soap or hard rubbing is a mistake and may 
cause troublesome dryness or irritation of the skin. 

Clothing. — The material for the underclothing should be 
soft and non-irritating. In the summer it may be of cotton 
and for winter part wool and cotton. The clothing should fit 
loosely and there should be no constricting bands and heavy 
seams. Buttons can often be advantageously replaced by tapes. 
The abdominal binder should not be worn after the third month 
unless the infant is delicate and underweight or has an umbilical 
hernia. In the winter the band with shoulder straps may be 
worn as an extra protection to the infant's abdomen. 

The diapers should not be too bulky or applied too tightly. 
Stockinet is light and more absorbent than linen and less expen- 
sive. Stress should be laid upon the importance of promptly 
removing soiled diapers and carefully washing them and then 
rinsing in plain water before they are again applied. 

The Mouth and Teeth. — In cleansing the baby's mouth 
great care should be exercised not to injure the delicate mucous 
membrane and thus invite infection. The use of a swab of 
cotton dipped in a 2 per cent boric acid solution is a safer 
procedure than inserting the covered finger into the mouth. 
In the case of thrush borax should be used in place of boric acid. 

The care of the teeth has an important bearing on the child's 
general health. Indigestion, enlarged tonsils and cervical 
adenitis are often directly traceable to dental caries. Malocclu- 
sion also seriously affects the child's health. As in the case of 
adults, we should always examine the teeth for a focus of infec- 
tion in all obscure ailments of possible infectious origin. 

Sleep. — The healthy infant is a good sleeper, usually not 



HYGIENE AND NURSING 



being awake more than an hour at a time and only waking for 
the purpose of nursing. After the sixth month it gradually 
becomes more wide awake during the day, requiring usually 
one or two naps, and about twelve hours sleep at night until it 
is a year old. From this time on until the fourth year it should 
sleep twelve hours at night and have a daily nap. 

Children should be carefully trained in regular habits of 
sleep. The most common causes for disorders of sleep are 
improper training, indigestion, frequent nursing during the 
night and sometimes local disturbances such as too much 
clothing, phimosis and seat-worms. 

The Bowels. — The infant can be taught to form the habit 
of having regular bowel movements by placing it on a chamber 
held on the nurse's lap and starting the movement with a 
suppository if necessary. This training can be begun as soon 
as the infant is able to sit up. 

The infant should have a bowel movement once in twenty-four 
hours at least. If allowed to go over until the next day the 
movement may become hard and difficult to pass and the anus 
may be torn. This leads to the development of a fissure with 
painful defecation and consequent troublesome constipation. 

Airing. — The nursery should be sunny and well-ventilated 
without being draughty. If the child is allowed to crawl the 
floor should be suitably covered. A pen is an excellent device 
for keeping the infant out of harm and giving it full opportunity 
to exercise and learn to walk. 

Ventilating the nursery in winter is best accomplished by 
having the windows open in the adjoining room until the air 
has been perfectly purified, when the windows should be closed 
and the communicating door opened to allow a diffusion of the 
atmosphere from one room to the other. Once a day, however, 
when the infant is out of the nursery, it should be thoroughly 
aired. 

As a rule, in the spring and fall an infant may be taken out 
into the fresh air at one month and even earlier during the 



4: DISEASES OF CHILDREN 

summer. During cold weather, however, an infant under three 
months should not he taken out of the house, and after that age 
only during the sunny hours of the day. The precautions 
necessary to be observed in taking a child out in its coach are 
that it be kept out of the wind, that it be sufficiently covered and 
that the sun does not shine directly into its eyes, but there is no 
valid objection to allowing a child to sleep in the open air in 
clement weather providing the above precautions are taken. 

Statistics show that infants require more airspace, propor- 
tionately, than adults, and that overcrowding is a prolific source 
of ill-health among children. This is especially the case in 
institutions and hospitals for children. 

Exercise. — The infant gets its exercise in crying and in the 
non-volitional movements which it performs. Playing with 
toys and creeping and walking soon become more effective forms 
of exercise, however. Older children require exercise of a more 
strenuous kind, such as walks in the open air, games, etc. A 
cold sponge bath every morning aids greatly in the physical 
development of the child. Fatigue and over-exertion in all 
forms of sport and exercise are to be carefully guarded against. 

Premature and Delicate Infants. — The period of via- 
bility in a premature babe cannot be arbitrarily stated, as the 
condition of the infant plays an important role as well as its 
age. The period of viability has been usually fixed at twenty- 
eight weeks, but premature infants of twenty-four weeks have 
been successfully raised. 

The fetus at the eighth lunar month weighs 3-*- lbs. and 
measures sixteen inches in length. The skin is wrinkled and 
the body is covered with lanugo. At the ninth lunar month it 
weighs 5 lbs. and measures eighteen inches in length. At the 
tenth lunar month, or term, it weighs 7 lbs. and measures twenty 
inches in length. The main problems with which we are con- 
fronted in caring for the premature infant are to maintain 
body-heat and to supply suitable nourishment. 

Infants weighing four pounds and over can frequently be 



HYGIENE AND NURSING 

reared without the use of an incubator. The body should be 
enveloped in a thick layer of cotton and in place of diapers, 
pads of gauze should be used. The entire body is then wrapped 
in a blanket and hot water bags applied to the feet and sides of 
the body or the infant may be placed upon an electrically 
heated pad. Daily inunctions with warm oil may be given 
but no baths. 

Breast-feeding is usually essential to the successful rearing 
of the premature infant. The milk should be drawn from the 
breast with a pump and collected in a sterile receptacle. It is 
then best administered to the child with a medicine-dropper, 
the milk being dropped well back into the pharynx, four drams 
of nourishment being given every 2 hours. If the infant 
cannot be made to take sufficient nourishment in this manner, 
gavage must be employed. If breast-milk cannot be obtained 
whey may be tried or a weak milk formula of one part boiled 
milk to two or three parts water and five per cent sugar of milk. 

The Care and Nursing of Sick Children. — In all acute 
illnesses the child should be kept in bed. Infants may occasion- 
ally be held in the mother's lap if they are very fretful and 
especially in the case of bronchopneumonia or protracted intes- 
tinal disturbances a change in the position of the patient is 
desirable. Unnecessary handling of a sick infant must, of 
course, be avoided. The child should be kept as quiet as pos- 
sible, both mentally and physically; in the case of a serious 
illness only one attendant should be with the child at a time. 

Temperature of the Sick Room. — The sick room must be 
kept well ventilated and not too warm, from 60 to 68 degrees F. 
In the summer an electric fan may be used to keep the air in 
motion but it should not be directed against the patient. The 
cold air treatment of pneumonia is only applicable to the lobar 
variety. Even in these cases it should not be carried to extremes. 

Clothing. — In summer a light night shirt is all that is 
required; in cool weather the patient may also have a light 
undershirt to wear especially if the windows must be kept wide 



6 DISEASES OF CHILDREN 

open. Cotton- jackets, spice-bags and all forms of plasters 
are obsolete. 

Heat. — Heat is perhaps the most useful of all non-medicinal 
therapeutic measures and has a wide field of applicability. In 
painful inflammatory conditions it acts promptly by relieving 
tension and hastening resorption. The old fashioned poultice 
is rapidly being replaced by hot fomentations. Dry heat is 
most conveniently applied by means of hot-water bags and 
heated flannel. It must be remembered that the child's skin 
is more sensitive and more readily burned than an adult's, for 
which reason proper precautions must always be taken. 

Baths. — By means of the bath we are able to apply heat or 
cold most rapidly to the entire body. Hot baths are often useful 
in collapse and asphyxia neonatorum; by adding a tablespoon- 
f ul of powdered mustard to the warm bath we have an excellent 
means of relieving serious congestion of internal organs, through 
its derivative effect. The bran bath is most useful in cases of 
eczema or other excoriating conditions of the skin. 

The tepid sponge-bath must be used once or twice daily in all 
illnesses regardless of the presence of a rash or a chest condition. 
In case of high fever a cold sponge-bath may be given every 
two or three hours. The full cold bath is rarely used in children. 

Packs. — Packs are highly efficient antipyretics and dia- 
phoretics. The cold pack is applied by wrapping the child in a 
sheet wrung out of cold water, the sheet being surrounded by 
a dry blanket. When used to reduce fever it can be reapplied 
hourly. In pneumonia the pack is often restricted to the chest. 

The hot pack is most useful in nephritis and uremia. A 
light blanket is wrung out of hot water and applied as above. 

The hot mustard pack is prepared by adding a little ground 
mustard to the hot water; it is employed in convulsions, con- 
gestion of the lungs and of the brain; also to bring out tardy 
eruptions. While in the pack the head should be sponged with 
cold water or water and alcohol. 

Inhalation. — The inhalation of steam is very beneficial in 



HYGIENE AND NURSING 7 

respiratory ailments, especially in the case of croup. In the 
absence of a specially-constructed "croup-kettle," an ordinary 
tea-kettle heated by an alcohol stove or better, by an electric 
stove, may be used, the steam being directed under a sheet over- 
hanging the child in the fashion of a tent. 

Lavage. — The apparatus for carrying out lavage in children 
consists of a soft rubber catheter, connected with a piece of 
rubber tubing two feet long by means of a piece of glass tubing, 
and a medium sized glass funnel attached to the free end of 
the rubber tube. This apparatus may also be used for gavage. 
For the new-born infant a number 14 French soft rubber 
catheter should be used; in older infants a number 16 French 
scale is the proper size. In the new-born the catheter reaches 
the fundus, when introduced to the length of eight inches; in 
an infant of three months it must be inserted nine inches and 
in older infants from ten to twelve inches. I am in the habit 
of enlarging the eye of the catheter to facilitate the passage of 
mucus and curds. The passage of the tube into the infant's 
stomach is, as a rule, unaccompanied by any depression and 
causes only slight discomfort. Lavage is useful in all cases of 
persistent vomiting and is a necessary diagnostic procedure in 
certain gastric conditions, notably pyloric stenosis. 

Lavage is performed as follows: The infant is held upright 
and seated on the nurse's lap, and covered with a towel to 
prevent soiling the clothing. The catheter is then inserted in 
the pharynx with the right hand, its tip following the index 
finger of the left hand which presses down the base of the tongue. 
Wetting the catheter with plain water is sufficient as a rule ; if 
there be abnormal dryness of the mucous membrane, there is no 
objection to the use of olive oil. The child may make efforts 
at deglutition as soon as the catheter reaches the pharynx, in 
which case it glides down easily into the esophagus. More 
frequently, however, it gags, interfering with the operation. 
If we wait for a few seconds until the child draws in its breath, 
a gentle push will readily cause the catheter to enter the esoph- 



8 DISEASES OF CHILDREN 

agus. The catheter from now on reaches the stomach without 
difficulty. As soon as the catheter has entered the stomach the 
funnel should be lowered and the gastric contents permitted 
to flow out. Warm water or a weak solution of bicarbonate of 
soda are then poured into the funnel, a few ounces at a time, 
and allowed to run into the stomach and out again, until the 
water returns clear. 

Irrigation of the Colon and Enemata. — For the relief 
of simple constipation and for emptying the lower bowel the 
enema is all that is required. This is best administered by 
means of a bulb syringe with the child lying upon its back. 
Soap-suds give the best results with the low enema. 

When irrigation of the colon is to be carried out the child is 
placed on its left side upon a rubber sheet covered with a cloth, 
the hips being slightly elevated. A soft rubber catheter, number 
18 or 20 French scale, is attached to the nozzle of a fountain 
syringe, lubricated and carefully inserted into the rectum. The 
water is then allowed to flow in slowly, stopping the stream as 
the child makes efforts at expulsion. The catheter is gradually 
inserted further and further into the rectum as the latter is 
distended by the water, until it has been introduced from six 
to eight inches. The fluid will usually reach the colon without 
difficulty, but cannot pass into the ileum, although it is claimed 
that if the colon is not distended and the water allowed to flow 
in slowly, a closure of the ileo-cecal valve fails to take place. 

From six to eight ounces of warm, normal salt solution should 
be run into the bowel at a time and then permitted to flow out 
again through the catheter. After the process has been re- 
peated several times the water usually returns clear and the 
operation may then be discontinued. 

Irrigation of the colon is useful in diarrheal cases, especially 
if the stools are offensive or contain an abundance of mucus or 
curds. The same technique is employed when distension of the 
bowels with water is used in attempting to overcome an intus- 
susception. Enteroclysis is a safe and efficient means of averting 



HYGIENE AND NURSING 9 

circulatory failure in acute infectious conditions, and also for 
the purpose of aiding the elimination of toxins. This may be 
carried out according to the technique of Murphy, namely 
the "Murphy Drip." 



CHAPTER II. 

METHODS OF CLINICAL EXAMINATION. 

The Period of Infancy and Childhood. — Infancy is the 
early period of childhood, the state of an infant in arms, or the 
first two years of life. Clinically we divide it into the period 
of the newborn, the nursing period and the teething period 
which terminates with the completion of dentition, namely, 
the end of the second year. 

Childhood begins with the termination of the teething period 
and continues to the time of puberty. Certain diseases, not 
encountered in infancy now make their appearance, some of 
which are distinctive of childhood and may therefore properly 
be spoken of as "diseases of children." The child is, however, 
also susceptible to many of the diseases of the adult, but its 
immature anatomical and physiological development so modifies 
their clinical course that they are quite different from the same 
disease as observed in the adult. 

Mortality. — In recent years the death rate in early life has 
been markedly reduced through better sanitation and through 
the education of the public in the care of infants. In spite of 
preventive measures, however, a large number, approximately 
10 per cent, of all infants die in the early weeks of infancy from 
congenital debility. Many of these no doubt could be saved 
were the mothers able to nurse them. The total number of 
deaths during the entire period of infancy is still 25 per cent. 

Among the diseases responsible for this high death rate acute 
gastroenteritis heads the list furnishing about 30 per cent of 
all deaths. The acute gastrointestinal diseases of infancy occur 
almost exclusively during the summer. They are, to a great 
extent, preventable and therefore the outlook for a still greater 
reduction in infant mortality in the near future is hopeful. 

Congenital debility, prematurity and marasmus contribute 



METHODS OF CLINICAL EXAMINATION 11 

25 per cent to the death rate. Acute respiratory diseases, which 
occur most frequently during the winter months are responsible 
for about 20 per cent of the deaths. 

The History. — The first step in case taking is the interroga- 
tion of the patient, or in the case of an infant, the parent, for 
the purpose of ascertaining a history of the patient's ailment 
and of his state of health prior to the present illness. The 
family history must also be taken into account because of the 
important role played by heredity in many diseases. 

The history should be kept in writing and accurate subsequent 
observations of the case added thereto, thus making a complete 
record of each patient under the physician's care. 

The following data should be elicited in the order named and 
recorded in conjunction with the physical -findings in the case: 

Name of Patient, 
Age, 

Sex, 

Family History, 
Personal History, 
Previous Illnesses, 
Present Illness, 
Physical Examination, 
Laboratory Findings. 

The age and sex are important to note as they will either 
suggest or exclude certain diseases. For example, during in- 
fancy, a bowel disturbance is much more likely to be ileocolitis 
than typhoid fever. Convulsions in infancy are more frequent- 
ly functional and of less serious significance than in older 
children in whom they should suggest the probability of epilepsy. 
Again, sex may have an etiological bearing upon the case, cer- 
tain conditions being more frequently encountered in one sex 
than in another. 

The Family History should be inquired into for the purpose 
of determining the possibility of predisposition to or actual 
exposure to tuberculosis. A history of syphilis in the parents 



12 DISEASES OF CHILDREN 

can at times be obtained by direct interrogation. If this is 
denied, the history of repeated miscarriages and of previous 
still-born infants or of a previous infant dying with presumptive 
syphilitic manifestations will suggest the probability of this 
disease. Rheumatism, gout, diabetes and the physical vigor 
as well as the age of the parents should be inquired into. A 
neuropathic family history is frequently present in cases of 
nervous and mental diseases. The number of other children 
and their state of health should also be ascertained. 

The personal history begins with the state of the mother's 
health during pregnancy. The influence of pre-natal impres- 
sions is doubtful ; however, serious illness of the mother during 
pregnancy may affect the fetus to a marked extent. 

The mode of birth is important as protracted labor or instru- 
mental delivery may be the cause of a brain injury. The con- 
dition of the child at birth, whether asphyxiated and occurance 
of cyanosis or convulsions at this time, are important data. 

The weight at birth should be recorded and from it we 
can judge whether the infant's present weight is within 
normal limits. The mode of feeding, both past and present, 
must be known because of the importance of diet in the etiology 
of the nutritional disturbances of infancy. 

The age at which the infant first sat up, crept, and walked 
and the time of the eruption of the teeth and closure of the 
anterior fontanel are indications of the infant's physical devel- 
opment. Its mental development can be judged from the age 
at which it began to play with toys, recognize mother or nurse 
and talk. 

A list of the previous infectious diseases from which the child 
has suffered should be made. Since some of these will give 
immunity against a second attack while others cause increased 
susceptibility to a recurrence, this information may be of great 
diagnostic help. Again, certain of the infectious and con- 
tagious diseases leave sequelae or they predispose to lother 
infections. We should also determine whether the child has 



METHODS OF CLINICAL EXAMINATION 13 

shown a predisposition to certain ailments such as tonsillitis, 
rheumatic manifestations, bronchitis, gastrointestinal disturb- 
ances, nervous disturbances. 

The child's environment must be inquired into as this may 
prove to be the explanation for the child's condition or give us 
the source of the infection in the case of an attack of malaria, 
typhoid fever, etc. Tuberculosis is also contracted by direct 
exposure or from "house infection." During epidemics the 
early recognition of such diseases as scarlet fever and measles 
is materially facilitated by the knowledge that the child has been 
exposed to either one of these diseases. 

The nature of the present illness should now be recorded. 
The mode of onset, whether abrupt or with prodromata, the 
duration of the illness; the presence of fever — its character, 
whether uniformly high, remitting or intermitting. If other 
symptoms are present they should be carefully noted. Onset 
with vomiting, convulsions or sore throat are important data. 
The ratio of pulse, respiration and temperature should be con- 
sidered. Pain can be suspected without interrogating the little 
patient ; we can usually locate it by careful palpation or suspect 
its location from the child's actions. 

Physical Examination. — The first step in physical exam- 
ination is inspection. In order to inspect a patient properly he 
should be entirely stripped. The color, general state of nutrition, 
mental condition, attitude, facial expression and the presence 
of gross abnormalities such as a skin rash or a physical deformity 
can be taken in at a glance. 

The healthy infant is well nourished and plump, there being 
an abundance of subcutaneous fat. The skin is pink and 
becomes red when the infant cries. Pinching the skin leaves no 
folds because of the vascular fullness of the integument (turgor). 
The babe is active, observing its surroundings with interest and 
the extremities are in motion. The temperature does not vary 
from the normal during different periods of the day (infantile 
monothermia). 



14 DISEASES OF CHILDREN 

The head of the infant under one year is slightly larger in 
circumference than the chest and abdomen, the latter being 
about equal. Variations from this standard should be noted; 
also general emaciation; pallor; cutaneous eruptions and cyan- 
osis. Jaundice is frequently encountered in the new-born. 
Miliaria and sudamina are common in rickets. The tache 
cerebrate is a vasomotor disturbance encountered in meningitis. 
When the skin is irritated by sharply drawing the finger-nail 
across it a red streak will be left which persists for some time. 

If there be a deformity of the spine, we must determine 
whether it be due to Pott's disease, rickets, a unilateral pleural 
effusion, old pleuritic adhesions, or muscular weakness. The 
child should be laid flat upon its stomach and the body then 
lifted from the table by the feet. If rachitic, the deformity is 
at once reduced, but the kyphosis of Pott's disease is irreducible 
under all methods of manipulation. Retraction of the chest 
from pleuritic adhesions produces scoliosis, and in these cases 
we cau get the history of a former empyema. 

The head presents many diagnostic features. In rickets it is 
large and square; in hydrocephalus large but rounded, the 
fontanels are widely open and the eye-balls displaced downwards. 
In rickets there are often parchment-like areas representing a 
thinning out of the bony elements, known as craniotabes. 

The facial expression often points to the seat of trouble; 
for instance, the knitting of the brows in headache, which, 
when associated with strabismus, is a strong presumptive sign 
of meningitis ; the fan-like motion of the alse nasi in respiratory 
troubles, and the pinched expression of the face in abdominal 
disease. Roughly speaking, it can be said that the upper part 
of the face represents cerebral, the mid-portion respiratory, and 
the lower portion abdominal disturbances. Often one cheek 
will present a circumscribed redness, which is said to correspond 
to the side affected in pneumonia. This, however, is due to 
the cheeks having been lain upon and indicates vasomotor 
paresis. 



METHODS OF CLINICAL EXAMINATION 15 

The chest may present deformities, peculiarities of the ribs, 
deviations from the normal respiratory movements, abnormal 
movements and various skin eruptions. In the early stages of 
pleurisy the painful side becomes fixed and may produce a 
slight scoliosis. As the effusion is poured out the side bulges. 
In chronic pleurisy with adhesions the side becomes perma- 
nently retracted. 

In rickets the sternum is prominent from lateral compression 
of the costal cartilages (pectus carinatum) and the patho- 
gnomonic beading of the ribs, the "rickety rosary," is often 
present. In phthisis that portion of the chest over the consoli- 
dated lobe is flattened and does not move in the same degree 
as the unaffected side, the clavicle stands out prominently and 
there is often marked retraction of the ribs (flattening) in that 
region. The long, narrow chest with acute epigastric angle is 
found in asthenic individuals who are predisposed to phthisis 
and enteroptosis. 

In emphysema the chest assumes a rounded fullness, slight 
motion only being perceptible during respiration. After peri- 
carditis with adhesions the intercostal space is often seen to 
retract distinctly during the heart's systole. In pericarditis 
we may also note Broadbent's sign, i.e., systolic retraction of 
the lower ribs posteriorly on the left side. 

The limbs and joints must be examined for evidences of 
rheumatism or tubercular arthritis; the deformities of rickets 
and poliomyelitis anterior; the bone affections of syphilis and 
tuberculosis; the marked tenderness and subperiosteal hemor- 
rhages of scurvy should not be confused with arthritis. 

The reflexes. Among the superficial reflexes the plantar is 
of especial importanoe. Under normal conditions a flexor 
response is obtained, but in lesions of the pyramidal system 
hyperextension of the great toe occurs. This is known as 
Babinski's sign. In infants up to the age of learning to walk 
the response may be similar to the Babinski phenomenon. The 
great toe is drawn back; the toes are extended and spread out 



16 DISEASES OF CHILDREN 

and the foot is everted. The Babinski sign is more deliberate, 
however, and there is but a small amount of movement at 
the ankle. 

The knee-jerk is exaggerated in lesions of the upper motor 
neurons or irritation of the lower neurons. Diminished or 
abolished knee-jerks indicate a lesion in the lower motor neurons. 
In children it is best obtained in the dorsal position with the 
foot resting on the palm of the left hand, striking the tendon 
with a percussion hammer held in the right hand. 

Ankle clonus indicates disease of the spinal cord, from the 
first to the third sacral segments. 

The position assumed by the child during sleep and waking 
is important to note. We see the child burying its head in the 
pillow when there is photophobia ; lying on the back with limbs 
drawn up in abdominal inflammations ; persistently lying upon 
the side in acute pleurisy; the head drawn back and the neck 
rigid in meningitis; unable to lie in the prone position in the 
dyspnea of capillary bronchitis and heart disease ; impossibility 
of extending the leg upon the thigh when in the sitting position 
owing to the contraction of the flexor muscles, which disappears 
when the dorsal decubitus is assumed {Kernig's sign in menin- 
gitis) ; sleeping or comatose; crying out in sleep and gritting the 
teeth. During natural slejep the child assumes a position 
indicating complete relaxation, the respiration is of the abdom- 
inal type. Infants sleep with the arms drawn up and flexed, 
probably the position maintained during intra-uterine life. 

The character of the cry is often a help in diagnosis. The 
shrill, piercing cry of meningitis is pathognomonic. The hoarse 
cry of the new-born infant suggests syphilis. In otitis the cry 
is often continuous in spite of all that is done to humor the 
child. The recognition of the cry of hunger, pain and temper 
is more readily attained by observation than from reading. 
The natural cry is a loud, strong vocal effort accompanied by 
reddening of the face and does not last more than a few minutes. 
Abnormal cries are, as a rule, weaker in character and more 



METHODS OF CLINICAL EXAMINATION 17 

persistent. The cry of pain may be strong, but it is accom- 
panied by evidences of sufferings and distress, such as facial 
contortions tears, drawing up of the legs or bringing the hand 
to the affected part. The cry of hunger is a continuous, fretful 
cry, ceasing when food is offered. 

The inspection of the throat is left until the last because 
it usually causes the child to cry and so interferes with further 
examination of the case. The child must be firmly held and 
it is usually necessary to gag it in order to get a satisfactory 
view of the throat. Infants may be rolled in a sheet with the 
arms extended at the sides in order to prevent struggling and 
older children can be taken on the nurse's lap, the legs held 
between the nurse's knees and the arms and head controlled by 
the nurse passing her arms under the child's axillae from behind 
and then over the back of the head. However, children can be 
taught early to have the throat examined and if they are not 
unnecessarily gagged will offer little objection. 

In contagious diseases we should be prepared for the sudden 
cough which is likely to occur and spurt infectious material 
into the examiner's face. Often it is only necessary to allow 
the child to cry during which act a satisfactory view of the 
throat and mouth may be obtained. 

Palpation. — The sense of touch, properly trained, will give 
much valuable information in the study of sick children. The 
first thing that strikes our attention as w T e touch the child's body 
is the temperature. Fever, however, cannot be accurately es- 
timated by palpation alone. Dryness or moisture of the skin 
as well as roughness should be noted. Palpation of the head 
determines the state of the anterior fontanel and the sutures; 
the presence of cranio-tabes ; mastoid tenderness. 

From the head we descend to the chest, taking also the neck, 

where we often find scrofulous enlargements of the cervical 

glands. In an examination of the chest palpation is usually 

the first step, and if the child is crying we can determine the 

vocal fremitus. The child should be held by the mother in 
3 



18 DISEASES OF CHILDREN 

such a manner that it rests on one of her shoulders and presents 
its back to the physician. The hand is then placed on the back 
in order to determine the vocal fremitus ; the rattling of mucus 
in the bronchi is distinctly transmitted to the hands, in bron- 
chitis. The hands can then be placed on the sides of the chest 
and the respiratory movements of both sides compared. The 
left hand will now seek the cardiac area, by which means hyper- 
trophy or a thrill can often be detected. 

The abdomen is most satisfactorily palpated while the child 
is asleep, the warmed hand being gently introduced under the 
bed-covering. Distension or retraction of the abdominal wall 
was noted while inspecting. The trained palpating hand will 
recognize enlargement of the liver and spleen; the presence of 
enlarged mesenteric glands; impacted feces, etc. The abdom- 
inal muscles lose their normal tone in disease or they become 
rigidly contracted in abdominal inflammations. 

Abdominal pain may be a "referred pain" from the chest, but 
localized tenderness is of great diagnostic importance. Tender- 
ness over McBurney's point and rigidity of the right rectus is 
pathognomonic of appendicitis. Gurgling in the right iliac 
fossa together with tenderness is strong presumptive evidence 
of typhoid fever, but this is not a pathognomonic sign. 

The bladder may be felt in the hypogastrium when distended. 
A rectal examination should be made as a supplement to the 
abdominal examination in all doubtful cases. 

Percussion. — Percussion of the head is employed in eliciting 
Macewen's sign. The skull is percussed directly with the finger 
and in the case of distension of the lateral ventricles with fluid 
a hollow note is heard. It is an early sign of meningitis. 

In percussing the chest of a young child we must bear in mind 
the lesser dimensions of the thorax and the greater elasticity of 
the chest walls. This anatomical fact makes it more difficult 
to outline the heart boundaries than in older children. The 
thinness of the chest wall and the relatively large size of the 
bronchi gives the percussion note a hyperresonant character. 
Therefore light percussion should be used. 



METHODS OF CLINICAL EXAMINATION 19 

For percussion of the front of the chest the child should lie 
upon its back. For percussing the back, it should be held over 
the nurse's left shoulder with its arms about the nurse's neck. 
This is also the best position for auscultation. 

Percussion of the upper dorsal spines and the interscapular 
region for eliciting the sign of d'Espine is most satisfactorily 
performed with the child in the sitting posture and with the 
head renexed. In this position the region of the bronchial 
glands is also best auscultated. 

In the percussion of a superficial organ (thymus) or the 
superficial area of dulness of the heart (the "absolute dulness") 
the best results are obtained by using the middle finger of the 
left hand for a pleximeter and striking quick, gentle taps with 
the midde finger of the right hand. When striving to elicit 
deep dulness in order to outline a deep-seated organ like the 
spleen or to determine the deep ("relative") dulness of the 
heart or liver, the finger should be pressed deeply into the 
intercostal spaces and the percussion strokes dealt more strongly, 
avoiding loud percussion, however, which drowns out the finer 
shades of distinction between the notes and practically abolishes 
all border lines. In percussing, the examiner's finger also 
experiences the sense of resistance which is of especial aid in 
the detection of fluid in the chest. 

In percussing the chest, normally, the percussion note grad- 
ually increases in intensity both anteriorly and posteriorly as 
we descend and then gradually diminishes as the lower border 
of the thorax is reached. The increase in intensity in percussing 
downwards results from greater thinness of the thoracic wall — 
the pectoral muscles and the scapula and its muscles padding the 
upper part of the thorax considerably — and the flatter config- 
uration of the chest at its mid-portion. As we descend we 
impinge upon the deep dulness of the liver and spleen posteri- 
orly and the liver and heart anteriorly. 

The lower border of the lungs in the dorsal position is 
identical in children and adults, and not higher as Weil claimed 



20 DISEASES OF CHILDREN 

(Sahli). The following points reach the extreme lower border 
of the lungs : Eight mammary line, upper border of the sixth 
rib; left mid-axillary line, upper border of ninth rib; pos- 
teriorly, on either side of the spine, eleventh dorsal spine. 

The percussion note over the sternum is more intense than in 
the adult owing to the elasticity of the thorax. A slight shade 
of difference naturally exists and is apparent in percussion from 
an adjacent region of the thorax toward the sternum and over it, 
but it is not more pronounced than is the difference existing in 
the note over a rib, and in an intercostal space. Percussion of 
the sternum in children, therefore, gives more positive results 
than in the adult. In percussing from above downwards the 
upper boundary of the deep cardiac dulness may be traced by 
means of light percussion. The presence of the thymus gland 
may also be demonstrated in the upper sternal region in young 
children, when hypertrophied. 

Auscultation. — The position for auscultation is the same as 
recommended for percussion. Auscultation is most satisfactorily 
performed when the child is quiet but during crying we can 
estimate the vocal resonance and also hear rales at the end of 
inspiration. Crying is purely an expiratory act and therefore 
does not interfere with inspiratory sounds. 

Older children may be engaged in conversation when we wish 
to study the voice sounds. A binaural stethoscope with a small 
bell or chest-piece, is the instrument to be recommended. 

The heart may be auscultated posteriorly almost as well as 
anteriorly in infants and the murmurs of congenital heart 
disease are often better heard between the scapulae than over the 
cardiac area in front. The heart should always be examined 
as a matter of routine and before the infant begins to cry as it 
cannot be auscultated during crying. 

Normally the first sound at the apex is the loudest sound of 
the heart. Next in intensity is the pulmonary second and 
lastly the aortic second sound. The rhythm is trochaic (Hoch- 
singer). The pulmonary second sound is normally louder than 



METHODS OF CLINICAL EXAMINATION 21 

the aortic second up to the tenth year. The first sound of the 
heart develops its booming, muscular quality during the second 
year. Prior to that time the heart sounds are of the embryonic 
type. 

Auscultation is seldom of use in abdominal conditions in chil- 
dren, excepting to determine the absence of intestinal move- 
ments (peritonitis). 

The respiration of the child is of the puerile type, charac- 
terized by harsh respirations, somewhat bronchial in character. 
In infants, owing to the slight movements of the chest wall and 
the purely abdominal type of breathing, the respiratory sounds 
are feeble. 

As the right bronchus is of larger calibre than the left, the 
respiratory note is more intense on the right side. Broncho- 
vesicular breathing may normally be heard to the right of the 
spine in the scapular region. 

Occasionally during deep inspiration, especially during cry- 
ing, sub-crepitant rales may be heard at the apices (supra- 
clavicular region) and at the bases posteriorly. In pneumonic 
conditions we must be careful not to confuse harsh, rasping 
subcrepitant rales, characteristic in children, with pleuritic 
friction sounds. 

Pulse, Temperature, Respiration. — The pulse is normally 
rapid in children, gradually decreasing in frequency during 
childhood, attaining the average rate of 76 in males and 80 in 
females by the time of puberty. In young children the rhythm 
is variable and irregular, being influenced by the respirations 
(sinus irregularity). The pulse-rate is not a safe criterion of 
fever, which can only be accurately determined by means of the 
clinical thermometer. 

During the first weeks of life the pulse-rate varies between 
125 and 135 beats per minute. From the sixth to the twelfth 
month it is usually 105 to 115 and is more susceptible to crying, 
etc. From the second to the sixth year it may be said to vary 
within 90 to 105 beats; seventh to tenth year 80 to 90 beats, 
after which it gradually attains the average adult standard. 



22 DISEASES OF CHILDREN 

One of the most satisfactory results to be obtained in studying 
the pulse is when we compare it with the temperature and 
respiratory ratio. Thus in the beginning of typhoid fever 
the temperature may have risen several degrees above normal 
while the pulse rate is still unaffected. Later it may rise 
entirely out of proportion to the temperature. The pulse does 
not, therefore, rise in uniform ratio with the rise of temperature 
in all cases, although, as a rule, one degree of fever-heat is 
usually accompanied by an increase of eight pulse-beats. 

The number of respirations per minute does not correspond 
so closely to the temperature as the frequency of the pulse. In 
pneumonia the rate of respiration is entirely out of proportion 
to the fever and the pulse, and greatly quickened respirations 
should at once lead us to examine the chest. 

The temperature is best taken by inserting a clinical ther- 
mometer, lubricated with vaseline, into the rectum. It is 
usually a trine higher than in the mouth, but it is much more 
satisfactorily taken here, and far more accurately than in the 
axilla or groin. Diurnal variations in the temperature are 
of the same significance in children as in adults. 

The Urine. — Routine examination of the urine in infancy 
is just as important as in older children and should not be 
neglected because of the slight trouble necessary to obtain a 
specimen. Many cases of albuminuria and pyelitis are over- 
looked by a failure to make urinalyses especially in cases of 
fever of obscure origin. 

Specimens of urine can readily be secured in male infants by 
attaching a test-tube to the penis and leaving it there until the 
child has urinated. In the case of female children a small cup 
may be held in place over the vulva until a specimen is obtained. 
In many instances it is only necessary to seat the infant on a 
chamber and it will void urine voluntarily. 

The daily quantity of the urine increases gradually from an 
ounce at birth to six to ten ounces by the end of the second 
week. The amount is relatively large during early infancy, in- 



METHODS OF CLINICAL EXAMINATION 23 

creasing from six to twelve ounces at one month to sixteen ounces 
at six months of age. By the second year it may reach twenty 
ounces, and by the eighth year one quart. The specific gravity 
is relatively low during infancy, the percentage of solids also 
being low, but the amount of urine passed is greater in com- 
parison with the body-weight than in adults. The new-born 
voids a concentrated, highly colored urine leaving a pinkish 
stain of urates and uric acid upon the diaper. Micturition is 
characteristically frequent during infancy and the urine is 
passed unconsciously by the infant. At the end of the second 
year the child becomes conscious of the desire to urinate and 
it should learn to control urination at this time. 



CHAPTER III. 

THERAPEUTICS. 

The treatment of disease according to the homeopathic meth- 
od is based upon the law of similars enunciated by Hahnemann 
in his Organon of the Art of Healing which he expressed by 
the formula "similia similibus curentur." There has been 
much arguing pro and con as to whether this formula represents 
a law of cure or whether it is only a rule of practice. This 
question is of minor importance, however, and is not essential 
to an understanding of the principles of homeopathic practice. 
The latter is based entirely upon the homeopathic materia 
medica which has been developed from studies of the effect of 
drugs upon healthy individuals, the symptoms induced by the 
ingestion of the various drugs being carefully noted and classified 
and thus a more or less complete symptomatology of each drug 
obtained. This method of study was designated by Hahne- 
mann as "drug proving." The homeopathic materia medica 
also includes in its symptomatology the pathological effects of 
drugs observed in animal experiments and in human beings 
who have been poisoned by such drugs whenever these data are 
available. In this manner the pathological action of drugs 
has been learned and the homeopathic relationship of certain 
drugs to certain diseases has been established. Again, some of 
the symptoms which have crept into the materia medica are 
entirely empirical; their therapeutic usefulness having been 
established by clinical experience. !N"o claim is made that such 
symptoms always indicate homeopathic drug action and we are 
fully aware of the fact that the homeopathic materia medica 
needs a re-proving of many of its drugs. However, these 
empirical, or "clinical" symptoms should be accepted for what 
they are worth and not used as an argument against the homeo- 
pathic method. 



THERAPEUTICS 25 

The isopathic principle has become a most important factor 
in modern therapeutics; this is especially seen in the strides 
made by vaccine therapy in recent years. The cure of anaphy- 
lactic conditions such as hay-fever and asthma by the use of 
foreign proteins for the purpose of de-sensitization is another 
example of isopathy. This principle has also been applied to 
the cure of poison ivy dermatitis with the tincture of rhus 
toxicodendron by Schamberg {Jour. Amer. Med. Asso., Oct. 
18, 1919). While these isopathic methods are, strictly speak- 
ing, not homeopathic, still they embody the same idea of the use 
of a single remedial agent administered in small doses for the 
purpose of bringing about a systemic curative reaction. 

In the treatment of the sick all accepted therapeutic methods 
have their place. Purely physiological effects such as are 
obtained from the administration of strychnia, digitalis and the 
bromides are needed in certain instances. Palliatives are fre- 
quently called for and are necessary adjuvants to the armamen- 
tarium of the physician. Specifics also occupy their proper 
place in medicine, notably quinine in malaria and mercury in 
syphilis. The former is an example of chemotherapy; the 
latter is a striking example of similia similibus curentur. The 
symptoms induced by small doses of mercury in individuals 
with an idiosyncrasy to this drug and the pathological mani- 
festations of chronic mercurial poisoning present a similarity 
to many of the symptoms of syphilis which cannot be explained 
as a mere coincidence. 

Dosage. — The history of the homeopathic dose is given by 
Richard Hughes in his Manual of Therapeutics as follows, 
"When Hahnemann first began to prescribe medicines according 
to the rule 'similia similibus' he gave them in the usual quan- 
tities. It is not surprising that his patient's symptoms, even 
though ultimately removed, were often in the first instance 
severely aggravated. So Hahnemann reduced his dose accord- 
ingly. At what stage of this reduction he found that fractional 
quantities of a smallness hitherto undreamt of exercised a potent 



26 DISEASES OF CHILDEEN 

influence, I cannot say. But once satisfied of the power of 
infinitessimals, he adopted them with enthusiasm as a part of 
the new system of medicine he was inaugurating." 

For a long time Hahnemann's opponents looked upon his 
infinitessimal doses as scientifically undemonstrable and there- 
fore unworthy of any serious consideration. We have learned 
in recent years, however, that a number of substances exert their 
specific effect in doses which are practically inconceivable and 
too small for demonstration by ordinary chemical or physical 
tests. The internal secretions and vitamins belong notably to 
this group. Granting, however, the possibility of the action 
of drugs in infinitessimal doses, still there is no necessity for 
the employment of infinitessimals in order to practice homeop- 
athy. The dose in which the remedy is used is not the principle 
upon which homeopathy is based. The full physiological dose, 
however, cannot be employed for the purpose of obtaining a 
homeopathic curative effect. Hahnemann's original intent in 
recommending smaller doses than the usual physiological 
one was to avoid the production of medicinal aggravation of the 
symptoms present. Thus, while small doses of ipecac will 
relieve certain forms of vomiting, a full dose would aggravate 
the same. 

To the beginner in homeopathy and to those not in sympathy 
with the theory of drug attenuation small doses of the tincture 
or the lower dilutions and the lower triturations are recom- 
mended. Let the dose just fall short of producing a medicinal 
aggravation and if the remedy is homeopathically indicated a 
curative effect will follow. Accordingly, the liquid remedies, 
excepting the very poisonous ones, may be administered in doses 
of one or two drops of the first or second decimal dilution and 
repeated every two hours or more frequently if necessary in 
acute conditions. In young infants the use of the third decimal 
dilution is preferable. When making use of insoluble sub- 
stances such as the carbonate or phosphate of lime (calcarea 
carbonica and calcarea phosphorica) , the phosphate of iron 



THEEAPEUTICS 27 

(ferrum phosphoricum) , the red iodide of mercury (mercurius 
iodatus ruber), etc., the third decimal trituration should be 
employed. Some of these insoluble substances notably the 
mercurial preparations are, however, active even in their crude 
state. The interesting experiments conducted by Dr. Percy 
Wilde and published in the Journal of the British Homeopathic 
Medical Society, Jan., 1902 demonstrate that the process of 
trituration induces changes in the physical property of the 
substance thus treated, converting apparently inert substances 
into a state in which they can enter into chemical combination 
with the cells of the human economy. 

PRESCRIBING IN DISEASES OF CHILDREN. 

Prescribing homeopathic remedies for children presents 
certain apparent difficulties which are not encountered in pre- 
scribing for adults. Infants and young children are not able to 
tell us concerning their pains, discomforts and sensations and 
when they are old enough to answer questions the answers are 
frequently misleading. Pains are, as a rule, incorrectly located 
and their true location must be ascertained by our clinical skill. 
Such modalities as aggravation or amelioration from rest or 
motion ; from hot or cold applications ; from pressure and from 
lying upon the affected side; and such symptoms as nausea, 
thirst, photophobia, sore throat, tenesmus, etc., cannot be elicited 
by questioning the little patient. However, they can all be 
recognized by careful observation, and the history, inspection 
and the physical examination of the patient will give more 
accurate information than interrogation. 

The selection of the homeopathic remedy should be made by 
a process similar to that employed in arriving at a diagnosis. 
First of all we should endeavor to determine the seat of the 
trouble and the nature of the pathological process which is 
responsible for the symptoms present. In acute illnesses there 
may be an infection with predominance of local or general 
manifestations. Fever will be present in all of these conditions. 



28 DISEASES OF CHILDREN 

When upper respiratory symptoms predominate aconite and 
gelsemium are indicated. They must be differentiated by the 
appearance of the child, in the case of gelsemium it is heavy 
and listless, there is general aching and lassitude as in grippe 
and the fever is not high. In the case of aconite the fever is 
high and is ushered in with a chill ; the patient is anxious and 
restless and tosses about from side to side. The feel of the skin 
may be deceptive as to the degree of fever present. In cases 
in which aconite is indicated the body surfaces may feel cool 
especially during the chilly stage while the rectal temperature 
may register 103° to 104° ; the belladonna case, on the other 
hand, owing to the dilatation of the cutaneous vessels, presents a 
hot body surface and the child may appear to have a very high 
fever when in fact the rectal temperature will register lower than 
in the former instance. Gelsemium is indicated in simple coryza 
and grippe cases while aconite is more suited to the beginning 
of bronchial and pulmonary inflammations. When throat 
symptoms dominate the clinical picture belladonna will 
suggest itself rather than aconite; if joint symptoms are present 
we will incline to bryonia rather than to aconite or belladonna. 
Fever alone is therefore not sufficient clinical basis for a pre- 
scription and that is why the homeopath gives aconite in one 
case, belladonna in another and gelsemium in still another type 
of case. 

The appearance and behavior of the child is of great help 
in prescribing. It may be pale or flushed ; the skin hot and dry 
or moist ; it may be listless and apathetic or restless and irritable. 
It may lie with its face buried in the pillow, or turning from 
side to side, or carefully maintaining a fixed position on one 
particular side. It may lie flat on its back and make no effort 
to move. These are all symptoms which suggest certain reme- 
dies just as they suggest certain clinical conditions. 

Gastrointestinal symptoms which are purely due to dietetic 
errors are of little significance from the standpoint of the 
prescriber because the correction of the diet is all that is neces- 



THEEAPEUTICS 29 

sary. Such symptoms as the vomiting of tough curds or the 
passage of curds in the stools; colic; constipation and simple 
diarrhea promptly disappear when the milk is properly modified 
and given in the right amount and at the right intervals of 
feeding. When, however, the dietetic factor has been active 
long enough to bring about an inflammatory reaction in the 
mucous membrane of the gastrointestinal tract or when infection 
is added, then a condition arises in which it not only becomes 
necessary to remove the cause as far as we can by a strict regula- 
tion of the infant's food but we must also prescribe for the 
symptoms which have associated themselves with the dyspepsia. 
The same holds good in the case of the dyspeptic and nutritional 
disturbances which result from prolonged improper feeding. 
The food intolerance; the diarrhea or constipation; the pallor, 
fretfullness and emaciation present in these cases are symptoms 
which call for a so-called "constitutional" remedy. 

In the acute digestive disturbances there may be a predomi- 
nance of local or of general symptoms as in the case of the 
infectious diseases. When vomiting is a predominating symp- 
tom ipecac is suggested as the remedy ; in the case of a simple 
diarrhea with undigested food particles chamomilla will be 
thought of. The character of the stool, however, must be care- 
fully studied in order to make an accurate prescription. Thus, 
frequent, large, yellow or greenish, liquid stools, expelled with 
gas and causing excoriation of the buttox call for podophyllum. 
Greenish stools containing mucus and curds with marked pee- 
vishness; distended abdomen and colic is a mild dyspeptic 
condition usually observed in teething infants and relieved by 
cliamomilla. Intestinal disturbances with colicky pains re- 
lieved by pressure are helped by colocynthis. This symptom 
is elicited by observing that the infant is comforted and stops 
crying whenever the nurse lays it on its stomach, across her 
lap. In the case of chamomilla the child is promptly comforted 
by being carried around. When the stools contain mucus and 
blood indicating an infectious diarrhea mercurius sol. is indi- 



30 DISEASES OF CHILDREN" 

cated. Other remedies beside mercurius present these symp- 
toms and must, therefore, be differentiated. When there is 
vomiting and marked prostration arsenicum album comes to our 
mind. When tenesmus is pronounced mercurius corrosivus is 
better indicated than mere. sol. Cases with marked toxemia 
will suggest remedies like belladonna,, cuprum ars., helleborus 
and rhus tox. 

In prescribing for the acute respiratory affections a know- 
ledge of the pathology of the condition under treatment is 
necessary in order to select the proper remedies. This holds 
good in almost all diseases and whenever the selection of a 
remedy is based on drug pathogenesy instead of on subjective 
symptoms, the prescription is bound to be more accurate and the 
results will be better. Subjective symptoms and certain 
modalities are unquestionably useful in prescribing but their 
use is chiefly to differentiate between a group of remedies all 
of which have a similar pathological relationship to the case 
under consideration. This point is particularly well illustrated 
in the pneumonias. There are two well-known types of pneu- 
monia, the catarrhal type or bronchopneumonia and croupous 
pneumonia. The remedies which are most frequently indicated 
and useful in the catarrhal type are those which affect chiefly 
the mucous membranes and set up catarrhal inflammations. 
The most important members of this group are belladonna, 
ipecac, mercurius and tartar emetic. In lobar pneumonia we 
must turn to a different group, namely one whose pathology 
corresponds more nearly with that of vascular engorgement and 
croupous exudation and aconite, bryonia, iodine and phosphorus 
come to our mind. 

Belladonna is a most useful remedy in the early stages of 
bronchopneumonia indicated by the dry, paroxysmal cough; 
high fever with flushed face and cerebral excitement. Many 
capable clinicians believe that when belladonna is used early a 
large number of cases of bronchitis can be aborted and that the 
extension of the process into the finer bronchi and air cells 
can be arrested. 



THERAPEUTICS 31 

Ipecac is indicated when the catarrhal symptoms predominate 
and when the chest seems literally filled with mucous secretion. 
The cough is associated with gagging and vomiting of mucus. 
When the secretion accumulates in the finer tubes the clinical 
picture of a capillary bronchitis develops. Cyanosis gradually 
develops and the child is no longer able to discharge the secretion 
from the bronchi and the mucus collects in the larger tubes, 
producing coarse rattling rales. At this stage of the disease 
tartar emetic is indicated and it may still help us to pull the case 
through unless circulatory failure and pulmonary edema 
supervene. 

Bryonia occupies the unique position of being the most 
generally useful remedy in all forms of acute respiratory disease. 
It causes inflammation of the bronchi, lungs and serous mem- 
branes and its symptomatology covers the most important clinical 
features of the majority of cases of bronchitis and pneumonia. 
There is a hard, . deep, non-productive cough which is painful 
and which is made worse by talking, drinking, or bodily exer- 
tion. The child, therefore, lies quietly and resents being moved 
or disturbed. There is fever, headache, mild delirium, irritabil- 
ity and great thirst. The bowels are constipated. When 
pleurisy develops as a complication bryonia is still the best 
remedy for the case. 

Scilla maritima is useful in the severe types of broncho- 
pneumonia with hard, painful cough. The cough is more 
paroxysmal than that of bryonia,, there is free secretion in the 
bronchi as indicated by an abundance of moist rales over the 
bases of the lungs and there is more prostration than in a 
bryonia case. 

In croupous pneumonia we think of aconite in the first stage 
which is of sudden onset with chill or its equivalent; the child 
is excited and restless and chest symptoms may be slight or 
wanting. If there is cough with the characteristic blood- 
streaked sputum, ferrum plios. is the remedy of choice. Pleur- 
itic involvement calls for bryonia and it may be alternated with 



32 DISEASES OF CHILDREN" 

either aconite or ferrum pfoos. Bryonia is also indicated as 
soon as consolidation develops. Phosphorus is useful in the 
graver types of pneumonia with toxemia, pulmonary congestion 
and dyspnea; expectoration of pure blood. Hyoscyamus is 
indicated in the cerebral type simulating meningitis. 

A remedy which has been of great help to the homeopath in 
the treatment of poliomyelitis and lethargic encephalitis is 
gelsemium. The symptoms recorded in the provings and toxi- 
cological reports of this drug are very characteristic and corres- 
pond closely with some of the leading clinical manifestations of 
the disease mentioned. I am sure that we have all had occasion 
to see the good effects of this remedy in the cases of poliomyelitis 
which have come under our notice. In spite of the claims made 
for the efficacy of immune horse serum in this disease I cannot 
see that they are sufficiently striking to make a better showing 
than homeopathic treatment. 

The so-called constitutional remedy is one of the homeopathic 
podiatrist's chief assets. There is no longer any doubt in the 
minds of either school of medical practitioners that certain types 
of individuals are susceptible to certain diseases and that some 
react more strongly to certain drugs than others do. Vagotonia 
and sympathicotonia are terms which our old school colleagues 
recognize and understand but before these terms were introduced 
into medicine the observations made by homeopathic prac- 
titioners that certain individuals were hypersensitive to certain 
drugs and that small doses of such drugs administered to a 
susceptible individual would produce a striking drug effect were 
rejected as absurd and unscientific. Likewise the homeopath's 
insistence upon the importance of diathetic or constitutional 
abnormalities, or the dyscrasise, as we call them, was ignored. 
The dominant school, however, now recognizes many such 
dyscrasise, for example, exudative diathesia, lithemia, spasmo- 
philia, scrofula and status lymphaticus. 

In the homeopathic literature it has been the custom to refer 
to a certain type of child as representing a certain remedy. 



THERAPEUTICS 33 

Thus, we read of the calcarea carbonica baby; the sulphur 
patient; the pulsatilla female. This method of expressing a 
certain therapeutic idea has no doubt provoked mirth in the 
minds of those unfamiliar with the homeopathic method of 
drug study. However, the idea is a good one and the point 
which our materia medica teachers have attempted to make by 
this verbal formula is to present a mental picture of the clinical 
sphere of the drug. When they describe the calcarea child they 
draw a clinical picture of the type of child which needs calcarea 
carb. — the fair complexioned, fat infant with poor muscular 
tone, open fontanel ; delayed dentition ; sweating about the head ; 
large belly; large, pale constipated or sour dyspeptic stools. 
There should be no question in the mind of anyone that a 
remedial agent which will improve the calcium metabolism of 
such an infant will be the best possible thing for it and calcium 
given in the finely-divided form of a homeopathic trituration 
stands a better chance of doing this than crude doses of lime salts. 
The clinical type described under the iodine syndrome repre- 
sents glandular atrophy and marasmus. The keynote symptoms 
of graphites and sulphur will be encountered in infants pre- 
senting the exudative diathesis. The endocrinologist has gone 
perhaps further than the homeopath in his classification of 
individuals into certain types or "tropes" to indicate which one 
of the organs of internal secretion is at fault. In a case 
presenting distinct clinical evidence of glandular insufficiency 
the administration of the proper gland substance should be 
expected to give better results than medicines. This, however, 
is not the case excepting in hypothyroidism and we must still 
look to the constitutional remedy for help in many chronic and 
nutritional disorders. 



CHAPTER IV. 

INFANT FEEDING. 

Owing to the fact that by far the largest number of deaths 
occuring during infancy can be traced to disturbances of nutri- 
tion and diseases of the gastro-intestinal tract, infant feeding 
occupies the most conspicuous place in the specialty of diseases 
of children. 

Infant feeding may be divided into natural, or maternal 
feeding and artificial, or bottle-feeding, Nature has intended 
that the infant be fed at its mother's breast and whenever 
maternal feeding can be carried out it should be encouraged 
to the fullest extent. Artificial, or bottle-feeding is not a 
method of choice but one of necessity. Unfortunately a 
large proportion of all infants cannot enjoy the advantages of 
maternal nursing for which reason it becomes necessary to 
institute artificial feeding. Under these circumstances it is 
our duty to decide upon a proper substitute for woman's milk 
and to give the mother instructions in the preparation of the 
food as well as in the manner of feeding the same, namely, 
the amount to be given at a feeding and the number of feedings 
necessary in the twenty-four hours. Before, however, taking 
up the subject of feeding we will first discuss the underlying 
principles above referred to. 

ANATOMY AND PHYSIOLOGY OF THE DIGESTIVE TRACT. 

The mouth is dry during early infancy on account of the 
absence of salivary secretion. As the teeth begin to erupt saliva 
is secreted, at times excessively, causing the infant to "drool." 
The salivary glands are anatomically developed in early life 
and ptyalin can be demonstrated in the salivary secretion ; how- 
ever, owing to the fact that the babe receives its food in liquid 
form there is no need for saliva at this time of life. 



INFANT FEEDING 35 

The stomach is in an immature state at birth, the fundus 
being poorly developed. The lesser curvature occupies a more 
horizontal position than after the child walks. The pylorus, 
which is in the median line and covered by the liver in the fetus, 
gradually moves over toward the right as the child grows older. 

Vomiting occurs readily on account of the immature develop- 
ment of the sphincter muscle at the cardiac end. Dilatation 
of the stomach readily occurs from prolonged overfeeding, and 
hypertrophy with hyper peristalsis develops early in cases of con- 
genital pyloric obstruction. 

The gastric capacity is about one ounce in the new-born and 
there is a gradual and progressive increase at the rate of one 
ounce per month so that at one month the capacity will be two 
ounces ; at three months four ounces ; at six months seven ounces. 
After the sixth month the increase is not so great and we may 
allow nine ounces for a nine months' old infant and ten ounces 
at one year. 

The gastric juice of the infant is identical with that of the 
older child, with the exception that there is a smaller percentage 
of hydrochloric acid. Free hydrochloric acid cannot be demon- 
strated when the infant is on a diet of cow's milk because of the 
complete union of the acid with the casein. However, when 
barley-water is used as a test meal, the reaction for free hydro- 
chloric acid can be obtained. 

Milk is coagulated within a few minutes after entering the 
stomach by the rennin of the gastric juice. The whey is 
squeezed out from the curd and so the stomach begins to 
discharge the liquid portion of its contents before the child has 
finished his meal. A normal acid reaction of the gastric con- 
tents is necessary for the digestion to progress favorably, as 
the pylorus remains closed as long as the contents of the pyloric 
end of the stomach are alkaline. The addition of alkalies to 
the food in sufficient amount to make it excessively alkaline 
will therefore delay rather than assist gastric digestion. It 
will also neutralize the hydrochloric acid of the gastric juice 



36 DISEASES OF CHILDREN 

and deprive the child of the benefits of this nseful secretion, 
which possesses both germicidal and denaturizing properties, 
destroying bacteria and their toxins in the food to a great extent, 
and preventing foreign proteins from setting up anaphylactic 
reactions. 

The average emptying time of the stomach is about three 
hours. The time required for the digestion of a meal depends 
to a great extent, however, upon the character of the food, far 
more so than upon the amount taken. Woman's milk is more 
quickly digested and leaves the stomach sooner than a meal of 
modified milk. The carbohydrates are quickly ejected from 
the stomach into the duodenum. In fact this occurs as soon 
as the milk has coagulated, as has been stated above. As a 
result of this early passage of the whey into the intestine the 
stomach is really not distended to the full capacity of the 
amount taken at each meal, provided the infant has not been 
fed too rapidly. 

After the carbohydrates, the proteins leave the stomach, 
usually at the end of two hours ; the fats leaving last. The 
interval between feedings must, therefore, be gauged according 
to the composition of the food rather than according to the 
quantity given at each feeding or the age of the child. A food 
high in carbohydrates but poor in protein and fat leaves the 
stomach in a short time. High protein mixtures require a 
moderate length of time to digest — from two to three hours — 
while milk rich in fat, whether breast milk or a modified cow's 
milk, requires the longest periods for complete gastric digestion 
and should, therefore, be given at four hour intervals. 

The Intestines. After the food passes through the pylorus 
it enters the duodenum where intestinal digestion begins. The 
chyme is acid when first entering the duodenum, but is neutral- 
ized and rendered alkaline by the pancreatic secretion. The 
pylorus remains closed so long as the duodenal secretion is acid ; 
in this way the flow of chyme from the stomach is automatically 
regulated and is more or less intermittent. 



INFANT FEEDING 37 

The digestive function of the pancreatic secretion is three- 
fold, namely: proteolytic, amylotic and fat-splitting. The 
ferments are all present at birth but pancreatic activity increases 
with the growth of the infant. 

The pancreas does not begin to secrete until stimulated by 
the action of the secretion present in the intestinal mucosa. 
When the acid chyme reaches the duodenum it causes secretin 
to be set free. This hormone is carried to the pancreas by the 
blood current and activates the pancreatic cells. 

The biliary secretion contains a ferment which changes a 
pro-enzyme of the pancreatic juice into steapsin. The impor- 
tance of bile in the digestion of fat is thus explained. The 
yellow color of the normal breast-fed stool is due to the presence 
of bilirubin. In dyspeptic conditions bilirubin is oxidized 
into biliverdin giving the stool a green color. 

The succus entericus secreted by the small intestines contains 
specific ferments for converting disaccharids such as sugar of 
milk, maltose, and cane sugar into monosaccharids. 

THE STOOLS. 

The newborn infant expels a dark, greenish, tarry substance 
of semi-solid consistency from the bowels which is called 
meconium. Its composition is biliary and intestinal secretion 
from which most of the moisture has been absorbed and which 
has accumulated in the gut during fetal life. Epithelium, 
hairs and vernix caseosa are also present showing that the fetus 
swallows amniotic fluid. On the third day the discharges from 
the bowels become thinner, contain more mucus and assume a 
brownish-green color. This is identical in appearance and 
composition with the starvation-stool observed when a child 
is fed for several days on a diet containing no solid constituents 
such as barley-water, broth or tea. 



38 DISEASES OF CHILDREN- 

FACTORS INFLUENCING THE CHARACTER OF THE STOOLS. 

The diet is largely responsible for the appearance and charac- 
ter of the stools. The state of the digestion also affects their 
appearance and we must therefore differentiate between physio- 
logical and pathological deviations from the average normal. A 
yonng infant may have from three to four stools daily, while 
an older one will normally have from one to two in 24 hours. 

The frequency of the stool is greater in breast-fed than in 
bottle-fed infants and the consistency may be normally much 
thinner. A thin stool containing some mucus may simply 
indicate that the milk is poor in fat. The consistency of the 
stool is therefore largely dependent upon the amount of fat in 
the food. When the infant is fed upon a food containing fairly 
large amounts of protein and carbohydrate but a low percentage 
of fat the stools are usually soft and salve-like. When the 
food is rich in fat and low in protein the stools may be soft or 
semi-liquid and contain curds. In cases of overfeeding with 
both casein and cream the stools become large and formed, of 
a putty-like consistency and grayish color, due to the formation 
of calcium soap in the intestinal tract. The soaps produced by 
the union of fatty acids with the calcium salts of the intestinal 
secretion, are dry and insoluble and therefore produce trouble- 
some constipation. 

The color of the breast-fed stool is an orange-yellow due to 
the presence of unchanged bilirubin. In infants fed on cow's 
milk the stools are of a paler shade. Sometimes they become 
almost colorless, as a result of the reduction of bilirubin into 
hydrobilirubin or urobilinogen, through bacterial action. This 
is most frequently seen in fat indigestion with constipated stools. 
When high protein and low fat formulae are fed, the stools 
may have a brownish-yellow color. Barley and maltose prepara- 
tions give the stool a brownish color. In dyspeptic conditions 
resulting from fermentation of the sugar of milk in the food, 
the stool is usually green. 



INFANT FEEDING 39 

The reaction of the stool is determined by means of strips of 
red and blue litmus paper moistened with water. It is acid in the 
breast-fed infant as a result of the fermentation changes taking 
place in the intestinal canal. This is favored by the high sugar 
(lactose) and low protein content of the mother's milk. In 
bottle-fed infants the stools are alkaline as a result of putre- 
factive changes in the intestine. The reaction may be made 
acid by feeding high fat and low protein formulae and by means 
of high sugar formulae. There is, however, always danger of 
the fermentation process exceeding the normal limits in artifi- 
cial feeding. 

In the lower portion of the small intestine and in the cecum 
of the breast-fed infant the bacillus lactis aerogenes and the 
bacillus bifidus predominate. The latter is most prevalent in the 
colon. Both are saccharolytic, converting lactose into lactic acid. 
The bacillus bifidus is Gram positive in its behavior to stains. 

In the artificially fed infant the colon group of bacteria 
predominates. They are proteolytic, although in a medium 
consisting chiefly of carbohydrate they may set up fermentative 
changes. The colon bacillus is Gram negative. 

Aside from the higher protein percentage of cow's milk the 
putrefactive changes which take place in the albuminous intes- 
tinal secretion are also responsible for the bacteriological differ- 
ence between the intestinal tract of breast-fed and artificially fed 
infants. The protein-rich artificial food stimulates intestinal 
secretion to a greater degree than does woman's milk. The alka- 
linity of the secretion favors putrefaction as does also the 
relatively higher calcium content of cow's milk. Several factors, 
therefore, are operative in bringing about these proteolytic 
changes. 

ABNORMAL CONSTITUENTS IN THE STOOLS. 
Curds are one of the most important abnormal constituents 
of the stool and are usually associated with an excess of moisture 
and mucus, so that the stool becomes too soft or liquid. Such 



4:0 DISEASES OF CHILDREN 

a loose stool is typical of indigestion although in breast-fed 
infants several stools of this character may be passed daily 
without any evidence of dyspepsia. 

The majority of curds indicate fat indigestion. They are 
composed of neutral fats and calcium soap, resulting from the 
combination of the fatty acids of the food with the mineral 
bases present in the intestinal secretion. Fat curds may be 
soft and oily, imparting an oily stain to a piece of unglazed 
paper when crushed upon the same, if they contain an appre- 
ciable amount of neutral fat. When they are composed mainly 
of calcium soap they are dryer and more brittle. They always 
contain some adventitious protein matter which may give them 
a tough consistency. The large, dry, hard fecal masses en- 
countered in constipation from overfeeding are a good example 
of calcium soap stools. 

Casein, or protein curds, are far less common than fat curds. 
They only occur when unboiled cow's milk is used and so can 
readily be overcome by boiling the milk. Casein curds are 
tougher than fat curds and are hardened by the action of 
formaldehyde. The curd should be placed on a piece of filter 
paper and some formaldehyde poured over it. If it is essen- 
tially a protein curd its consistency will promptly be changed 
by the reagent. 

Chemical Examination of Curds. A protein curd will 
respond to the usual tests for protein such as the Xanthoproteic 
reaction and Piotrowski's reaction. It should be remembered, 
however, that a considerable proportion of the make up of curds 
and elements in the stool must be attributed to the albuminous 
intestinal secretion and to bacteria, and for this reason all curds, 
whether primarily resulting from undigested or unassimilated 
fat or casein, will be contaminated with extraneous protein. 

A washed portion of the curd is placed in a test tube, dilute 
nitric acid is added and the contents of the tube boiled. All 
proteins are dissolved by the action of such a hot acid solution, 
and the solution assumes a yellow color. When it has cooled, 



INFANT FEEDING 41 

a strong alkali, such as sodium hydroxide solution, is added and 
an orange-yellow color reaction takes place. This is the Xantho- 
proteic reaction. Piotrowski's reaction is obtained by adding 
to the above solution a drop of copper sulphate and then an 
excess of sodium hydroxide. The reaction is a violet color, 
becoming darker on boiling. 

Fat curds are not influenced by formaldehyde but they are 
melted by heat if acetic acid be added to break down the soaps 
and liberate the fatty acids. The latter will crystalize out 
on cooling. The various fat elements also exhibit certain 
peculiarities of staining which make their identification possible. 
The test is best carried out under the low power of the micro- 
scope. A small fragment of stool is placed on a glass slide, 
mixed with a drop of water and then a drop of dilute carbol- 
fuchsin stain is added and a coverglass applied. The soap 
particles present take on a pale rose color while the fatty acids 
take a deep red stain. 

Neutral fats do not take the fuchsin stain but can be demon- 
strated by treating a specimen prepared as above with alcoholic 
Sudan III. With this stain the neutral fats show up as orange 
colored droplets. The fatty acids take on a deep red. 

If a drop of glacial acetic acid be allowed to run under the 
edge of the coverglass and the specimen heated, the fatty acids 
are liberated and on cooling will appear as needle-like crystals. 

This test is of value to establish the identity of a given curd 
and it also gives an approximate idea of the amount of fat in 
the stool. In normal, well digested stools only a trace of soap 
and fatty acids will be found. The younger the infant, however, 
the less complete the assimilation of fat even under normal 
conditions. The presence of neutral fats indicates duodenal 
indigestion from excessive peristalsis or sugar dyspepsia, or it 
may be an early sign of fat overfeeding. Excess of soaps in 
the stool indicates chronic fat indigestion, usually as a result 
of overfeeding. Normally about 90 per cent of the fat is 
assimilated. 



42 DISEASES OF CHILDREN 

Bile is present normally in the breast-fed stool in the form of 
bilirubin, which gives the stool its bright yellow color. Under 
artificial feeding the biliary constituents are often changed. 
In constipated stools bacterial reduction takes place and most 
of the bilirubin has been changed to urobilinogen, so that the 
stools are much lighter in color. In fermentation disturbances 
the bilirubin has been oxodized to biliverdin, giving the stool 
a green color. When exposed to the air a loose stool which was 
yellow when passed, oxidizes to a green color. 

Bacteriological Examination. It has been stated that the 
breast-fed stool is Gram positive while the stool of the bottle 
baby is chiefly Gram negative. In the latter the colon bacillus 
predominates and this organism may act either as a fermentative 
or as a putrefactive agent. 

Among the pathogenic organisms demonstrable in the intes- 
tinal tract the most important are the dysentery bacilli of which 
there are several types. These organisms may at times be 
demonstrated in the stools of healthy infants but when they are 
found in a case of ileocolitis and give the agglutination reaction 
with the blood of the patient, they may properly be considered 
as an infective agent. Unfortunately the cultivation and 
identification of the dysentery group requires special laboratory 
facilities and technical skill and therefore cannot be carried 
out in general practice. Sometimes they can be identified as 
Gram negative intracellular bacilli (Grulee). 

The gas bacillus of Welch is looked upon by Kendall as the 
etiological factor in certain cases of infantile diarrhea and the 
interesting point in connection with this type of infection is 
that he considers the lactic acid bacillus, given either in the 
form of buttermilk or in culture, a therapeutic specific. Holt 
considers its presence in diarrheal cases purely accidental. 
Its identification is simple and therefore clinically practical. 
A small portion of the suspected stool is thoroughly mixed with 
several cubic centimeters of milk in a test tube, the tube is 
placed in a water-bath of cold water, the water slowly brought 



INFANT FEEDING 43 

to the boiling point and allowed to boil for three minutes. All 
bacteria are killed by this beat excepting the spores of the 
gas bacillus. After incubating the tube at body temperature 
for twenty-four hours the gas bacillus, if present, liquifies the 
major portion of the casein and the residue assumes a pinkish 
color and contains small gas bubbles. The odor of butyric acid 
is also evolved. The bacillus is a thick, short rod with rounded 
ends and is Gram positive. 

MATERNAL NURSING. 

The physician should insist upon the mother nursing her 
infant whenever this is possible. A frequent error, the gravity 
of which does not seem to be fully realized, is to wean the babe 
because the milk appears to disagree with the infant. There 
may be spitting up, colic or loose, curdled stools as a cause for 
this decision. The proper regulation of the intervals of feeding 
and the administration of a little hot water before each feeding, 
will overcome these apparent faults of the food. Again, the 
child may be weaned because the breast-milk is insufficient in 
quantity, not worth while, or too poor in quality to properly 
nourish. Here a resort to mixed feeding, administering an 
ounce or two of some appropriate modified milk formula after 
each feeding will give the infant practically all of the advan- 
tages of maternal nursing. 

There are, of course, definite contraindications to maternal 
nursing. The mother with open tuberculosis cannot nurse her 
babe on account of the drain upon her own vitality and the 
danger to the child. In poorly compensated heart affections 
the mother should always be relieved from the task of nursing 
her own babe. In Bright' s disease it will depend largely upon 
her ability to stand the strain. In eclampsia nursing is contra- 
indicated. 

The syphilitic mother should by all means nurse her baby if 
possible. Under no circumstances should the babe of a syph- 
ilitic woman be given to another woman to nurse. 



44 DISEASES OF CHILDEEN 

In acute affections of short duration nursing need not be 
interdicted but in sepsis or typhoid fever the infant should 
be weaned. 

The infant should be put to the breast as soon as the mother 
has recovered from the effects of the labor. This may be done 
twice daily and in the interim, at four hour intervals, a few 
teaspoonfuls of tepid water may be given. 

The secretion found in the breast before lactation is known 
as colostrum. This is a highly albuminous substance with 
laxative properties and appears to be essential to the welfare 
of the newborn. Infants that are denied the breast from the 
very beginning usually do poorly and are difficult feeding cases. 

By the third day the flow of milk is established and the infant 
should be nursed every three hours during the day and every 
four hours after 6 P. M., making seven feedings in the twenty- 
four hours. 

After the infant is two months old the midnight feeding may 
be omitted, making six feedings in the twenty-four hours. 
After the fifth month the intervals between feedings should be 
lengthened to four hours, so that there will be but ^.ve daily 
nursings. 

The duration of nursing is normally about fifteen minutes. 
It has been shown that the infant gets one half the contents of 
the breast during the first five minutes. During the second 
five minutes it gets an additional quarter of the total amount 
and during the third Hve minutes, the balance. If the child is 
not a vigorous nurser it may be allowed twenty minutes, but 
not longer. A child may fall asleep during nursing, from 
feebleness; under these conditions it may be nursed more 
frequently for a while until it has gained strength. If the 
quantity is insufficient it will fret and cry when taken from 
the breast. 

If the child's nose is stopped up it lets go the nipple every 
few seconds in order to get its breath. This may also occur 
from faulty position whereby the breast interferes with the 



INFANT FEEDING 45 

child's breathing. A sore mouth will cause the child to let go 
the nipple and cry with pain. 

The nipple should be washed before and after each nursing 
with a saturated solution of boric acid, but it is not advisable 
to wash out the baby's mouth between feedings. The breasts 
should be given in rotation. When the milk becomes scanty 
it may be advisable to give both breasts at a feeding but this 
should only be done if the infant drains both completely. 
Under these circumstances a bottle will usually be necessary 
between feedings. 

Indications for Mixed Feeding. — When the infant fails 
to gain, or actually loses weight and shows signs of hunger it 
is not getting a sufficient amount of food. Most frequently the 
quantity is deficient; at times, however, the milk of poor 
quality may account for this undernutrition. In both instances 
mixed feeding will have to be resorted to. 

If the examination of the milk shows it to be deficient in 
solids, particularly in fat, half an ounce of modified cow's milk 
may be given after each feeding. Under these circumstances 
it will be best to use a 10 per cent top-milk diluted with two 
parts of a 5 per cent solution of sugar of milk. 

Deficient quantity is best determined by weighing the child 
before and after each feeding. This simple procedure gives 
an approximate idea of the average amount of milk which the 
infant obtains at a feeding. The deficiency can then be made 
up by giving the child the proper amount of modified milk 
after each nursing. Thus, if a two months old infant only gets 
two ounces at each feeding we should give it one to two ounces 
of modified milk according to its weight, after each nursing. 
The best formula to use under these circumstances is the regular 
one-third whole milk diluted with two parts water and 5 per 
cent sugar added to the total quantity. 

The reason for giving the bottle after the feeding is to insure 
thorough emptying of the breast. Unless the child is hungry 
it will not nurse vigorously and so the breast will lose the physio- 
logical stimulus necessary to keep up the process of lactation. 



46 DISEASES OF CHILDREN" 

Alternating the breast with the bottle is more likely to result 
in the child weaning itself. The average infant will grow to 
prefer the bottle to the breast because it gets the food with so 
much less effort. Only when the breasts begin to fail in their 
function should both breasts be given at one feeding and a bottle 
at the next. 

INDICATIONS FOR WEANING. 

If the child is too weak to nurse, the milk should be pumped 
from the breast and fed with a spoon or medicine dropper. 
Weaning should always be put off as a last resort. Even if the 
infant only gets the benefit of the colostrum and two or three 
weeks of partial breast feeding it will have had help at a time 
when artificial feeding is most difficult to institute successfully. 

The imperative indications for weaning have already been 
mentioned. Menstruation and pregnancy are not necessarily 
indications for immediate weaning, so long as mother and babe 
are doing perfectly well. 

Cracked nipples may cause the mother great suffering, but 
a nipple shield will overcome this trouble. Abnormally formed 
nipples may also be made to serve the babe with the aid of a 
nipple shield. 

The gradual deterioration of the milk and the increasing 
demands of the organism for more protein and salts during the 
last quarter of the first year, make weaning at this time a 
logical matter. Should this time come in mid-summer it may 
be permissible to carry the child along on the breast until it is 
a year old, providing, of course, the. mother is able to continue 
with the nursing. It is advisable, however, to give a feeding 
once daily of a strained vegetable soup, in order to supply 
additional mineral salts, carbohydrate and vegetable protein. 

The infant should be taught to drink water from earliest 
infancy. This will make weaning much easier when the time 
arrives. Also, during the hot weather, the child may be given a 
few ounces of water daily with advantage. 



INFANT FEEDING 47 

False Indications for Weaning are dyspeptic symptoms 
such as vomiting, curds in the stools and colic. Usually these 
symptoms are promptly corrected by instituting four hour inter- 
vals when the infant has been nursed too frequently. Should 
the milk show an abnormally high percentage of fat we may 
give the babe a teaspoonful or two of warm water before putting 
it to the breast ; also cutting down the mother's diet. In case 
of persistent disturbance an ounce of barley-water between 
feedings together with omitting sugar and fat from the mother's 
diet will correct the trouble. 

Poor quality of the milk and deficient quantity should 
not lead to weaning but call for mixed feeding as described above. 

The Wet-Nurse. — Premature and congenitally feeble in- 
fants are most difficult to raise on artificial food and if the 
mother is unable to nurse, a wet nurse should be procured. 
Young infants who have been badly started on the bottle and who 
have developed a marked intolerance for cow's milk are in immi- 
nent danger unless they can be put to the breast. When the 
choice of a wet-nurse is therefore imperative it is indeed a time 
of trouble and tribulation for both the physician and the patient 
unless a woman well known to either of them is available. When 
it is impossible to obtain a nurse who can stay in the patient's 
home and nurse the infant for every feeding, we may be able 
to get good results from having the wet-nurse come to the house 
three times daily. Sometimes a woman who is nursing her 
own babe can be gotten for this purpose. The only require- 
ments necessary for a wet-nurse are that she be in good health 
and have a sufficient supply of average good milk. All other 
matters such as the period of lactation, whether or not she is 
nursing her own infant, her age, etc., are negligible. 

In most large cities wet-nurses may be obtained from the 
various Maternity Hospitals or through Child Welfare Bureaus 
and Directories for Wet-Nurses. Before accepting such a 
professional wet-nurse a certificate of freedom from tuberculosis 
and gonorrhea and a negative Wasserman should be demanded. 



48 DISEASES OF CHILDREN 

METABOLISM IN INFANCY. 

The newborn infant requires forty-five calories of food for 
every pound of body-weight, while the adult requires but twenty. 
The food requirement thus expressed in calories per pound of 
body-weight is called the "energy-quotient," and it furnishes 
a valuable guide for estimating the amount of food needed by 
the infant. The age of the infant and its weight, therefore, 
become the determining factors to decide the quantity and 
strength of the food to be used at the different periods of infancy. 
The so-called "Caloric System" of feeding is based upon these 
facts. There is, however, no such thing as a caloric system of 
feeding; the energy-quotient simply guides us in the dosage of 
the food and is a most valuable check against both underfeeding 
and overfeeding. 

Metabolism in infancy differs radically from metabolism in 
the adult and it is necessary to have a thorough understanding 
of this subject before one can grasp the fundamental principles 
of infant feeding. 

It has been estimated that the infant requires about one-sixth 
of its body-weight in food (woman's milk) during the first three 
months of its life; one-seventh during the second quarter; 
one-eighth during the third quarter; and one-ninth during the 
last quarter of the first year. Expressed in calories this cor- 
responds to about 45 C. per pound of body-weight for the first 
quarter, 44 C. for the second quarter, 42 C. for the third quarter 
and 40 at one year. 

The explanation for this very high demand for food at birth 
and the gradual decline in the demand, dropping to 40 C. for 
each pound of body-weight at one year, 27 C. at the age of ten 
years, and 20 C. at the time of attainment of full growth, or 
adult life, is self evident when we pause to consider that the 
infant is a rapidly growing organism and requires food not only 
for the production of heat and energy and to replace broken 
down tissues but also for the formation of new tissue and for 



INFANT FEEDING 49 

the multiplication of the body cells. As the infant grows most 
rapidly during the first months of life its food requirements are 
greatest at that time. Thus during the first quarter it gains 
on an average of half a pound a week, thereby doubling its 
birth weight at the end of the fifth month. After that time it 
gains about a third of a pound per week and so trebles its birth 
weight at the end of the first year. During the entire second 
year it gains only as much as it did during the first five months, 
and thereby quadruples its birth weight at the end of the second 
year. The growth of the child in length takes place correspond- 
ingly with the increase in weight, very rapidly in early infancy 
and gradually falling off. The growth of the child, therefore, 
is most active during early infancy. When the full adult type 
of the sex is attained, the height and weight of the individual 
become stationary. The amount of food required at the differ- 
ent ages, therefore, is largely dependent upon the rate at which 
the individual is growing. 

Another factor accounting for the high food requirements of 
the infant in comparison with an older child is the relatively 
greater body surface which the infant presents, for which reason 
the loss of body heat is proportionately higher in a small in- 
dividual than in a larger one. The great activity of the infant, 
especially cardiac and respiratory, and the larger amount of 
glandular energy expended in the digestion of the large amount 
of food needed daily are other factors influencing the food 
requirements. 

An important difference between the child-type of metabolism 
and the adult-type is that the adult has attained "nitrogen- 
equilibrium," while the child retains a large portion of the 
nitrogen taken in its food. In the adult, under normal con- 
ditions, as much nitrogen can be recovered from the urine and 
feces as was ingested with the food. The child, however, 
retains a large part of the nitrogen, utilizing the same in 
building up the body tissues. 

Food values are measured in calories and the great calorie 
5 



50 DISEASES OF CHILDREN 

(C) is employed in our calculations in dietetics. It represents 
the quantity of food in grams which will give off a sufficient 
amount of heat when burned in the calorimeter to raise one 
kilogram of water one degree centigrade. Since the process of 
oxidation enters so largely into the phenomena of metabolism 
this method of estimating the food, or fuel value of the various 
foodstuffs is both logical and practical. 

The fuel value or caloric value of the different foodstuffs 
is as follows: — 

One gram of protein 4.1 C. 

One gram of carbohydrate 4.1 C. 

One gram of fat 9.3 C. 



From the above figures it is possible to compute the caloric 
value of the various foods entering into the child's dietary and 
if we know how many calories the child needs daily we are in 
a position to check up its diet in a scientific manner. 

The following table gives the caloric value per ounce of 
a number of the more important foods employed in infant 
feeding : — 

Woman's Milk 20 C. 

Cow's Milk, 4 per cent fat 20 C. 

Cream, 16 per cent fat 54 C. 

Top-milk, 10 per cent fat 38 C. 

Top-milk, 7 per cent fat 30 C. 

Skimmed Milk IOC. 

Carbohydrate (the sugars) 120 C. 



The following table will be found useful in computing the 
number of calories present in the diets for older children. Some 
of these figures can be easily memorized if we remember, for 
example, the fact that one egg, a cubic inch of butter, a slice of 
bread weighing one ounce and a medium sized potato, have about 
the same caloric value: — 



INFANT FEEDING 51 

One egg 75 C. 

A piece of butter a cubic inch square 75 C. 

A slice of bread, weight one ounce 75 C. 

A medium sized potato 75 C. 

Olive Oil, one teaspoonf ul 75 C. 



Sugar or other carbohydrate (rice, etc., dry) — 120 C. per 
ounce. Lean meat equals about 30 C. per ounce. 

Protein Metabolism. — The protein molecule contains all 
of the elements needed for cell growth and cell multiplication. 
Growth is therefore dependent upon a sufficient amount of 
protein in the food. Carbon, hydrogen and oxygen are found 
in all foods, namely in carbohydrates, fats and proteins. The 
protoplasm of the cell, however, requires beside these three 
elements, nitrogen and phosphorus and these are found 
in the casein of the milk. Casein also contains a large amount 
of calcium which adapts it especially to the food requirements 
of the infant. 

During digestion the protein molecule is broken down into 
the elementary amino-acid groups of which it is chiefly com- 
posed, by the action of the digestive ferments and these cleavage 
products are absorbed into the general circulation and carried 
to the tissues where they are again built up or synthesized into 
the specific proteins of the various organs. 

The infant retains most of the nitrogen taken in the food 
because it utilizes the protein cleavage products in building up 
its tissues. Some nitrogen appears in the urine indicating that 
some of the radicals from the protein molecule have been used 
for heat production, or dynamogenic purposes. Nitrogen may 
also appear in the urine in the form of ammonia products, result- 
ing from an acidosis. The addition of carbohydrate to the food 
increases nitrogen retention if it is not pushed to the point of 
setting up a diarrhea. 

The feeding of milk mixtures containing a high percentage of 
protein (casein) does not produce metabolic disturbances such as 
fever or uremic manifestations nor does it upset the digestion so 



52 DISEASES OF CHILDREN 

long as there is not too much fat or sugar in the mixture to cause 
a primary digestive disturbance. It has been previously stated 
that the majority of curds found in the stools of bottle-fed 
infants consist of fat products and not of undigested casein; 
also that when true casein curds do occur they can be controlled 
by boiling the milk. A formula containing a high casein 
percentage, such as Finkelstein's "Eiweissmilch" is actually 
beneficial in fermentative dyspeptic conditions. Proteins 
stimulate the intestinal secretion and this secretion being alka- 
line, neutralizes the acids resulting from the fermentation. High 
protein in the food also inhibits fermentation. Under ordinary 
conditions, however, it is not advisable to administer larger 
amounts of casein than are found in the milk dilutions generally 
employed in infant feeding. 

Fat Metabolism. — The digestion and the assimilation of 
fat is not as complete as that of protein. The newborn passes 
a large amount of unassimilated fat in its stools in the early 
weeks of life but as it grows older fat digestion becomes more 
complete and there is an absorption of about 90 per cent of the 
fat present in the food. The normal bottle-fed infant also 
assimilates about 90 per cent of the ingested fat. 

The consistency of the stool depends largely upon the amount 
of fat residue which it contains. According to the investigations 
of Holt (American Journal of Diseases of Children, April, 
1919 and June, 1919) the fat of the stools of normal breast- 
fed infants averaged 34.5 per cent of the dried weight. In 
normal bottle-fed infants the percentage averaged 36.2. The 
soap per cent of total fat averaged about 73, being highest in 
the constipated stools. The soap is produced by the combination 
of unassimilated fatty acids with the alkaline mineral salts of 
the intestinal secretion. The soap of the constipated stool is 
dry and insoluble owing to the predominance of calcium salts. 

The formation of calcium soap stools is favored by milk 
overfeeding, as a result of which the child receives more protein 
and fat in twenty-four hours than it can digest or assimilate. 



INFANT FEEDING 53 

The excess of protein stimulates intestinal secretion and favors 
putrefaction changes in the gut, and this in turn favors soap- 
stool formation. Czerny has designated the clinical picture 
resulting from prolonged overfeeding, "Milchnahrschaden." 
There is loss of weight, fretfulness, pallor, tympanites and hard, 
dry, grayish, offensive stools together with excess of ammonia 
in the urine. A diet low in protein and high in carbohydrate, 
such as woman's milk, tends to diminish soap formation. Foods 
like Finkelstein's "Eiweissmilch" favor the formation of soap 
stools, owing to the presence of a large amount of protein and 
calcium salt entering into its composition. Peristalsis is thereby 
checked and diarrhea overcome. 

The long continued feeding of excessive amounts of fat may 
lead to the development of an acidosis. This is indicated by 
the presence of an excess of ammonia in the urine and of acetone 
and diacetic acid. A preceeding malnutrition, resulting from 
the overfeeding, favors the development of acidosis. The loss 
of alkaline salts through the increased intestinal secretion, 
which combine with the fatty acids in the stool and are thus 
excreted, leads to an increased ammonia production in the 
tissues in order to neutralize the urinary acids. Therefore, 
if through a disturbance of fat metabolism, oxybutyric acid 
and diacetic acid are formed in the tissues acidosis promptly 
develops because the organism has lost its power of neutralizing 
these acids in the blood plasma. The tolerance to fat, of 
course, varies widely in different individuals but the dangers 
of fat overfeeding must always be borne in mind. 

Carbohydrate Metabolism. — The carbohydrate found in 
milk is lactose, or milk sugar. Lactose is a disaccharid, as are 
the other sugars used in infant feeding. After the lactose 
reaches the intestines it is acted upon by an enzyme, invertin, 
which splits it into the monosaccharids dextrose and galactose. 
Cane sugar is acted upon similarly and is split into dextrose 
and levulose. Maltose is the end product of starch digestion; 
one molecule of maltose is split into two molecules of dextrose 



54 DISEASES OF CHILDREN 

through the action of invertin. Maltose is also split in the 
stomach to a slight extent by the hydrolytic action of the 
hydrochloric acid of the gastric juice. 

Starch is a polysaccharid ; it is hydrolyzed both by the ptyalin 
of the saliva and by the amylopsin of the pancreatic juice. 
Starch digestion takes place mainly in the intestine. The starch 
is first converted into a soluble form, or amylodextrin. This 
is further split into dextrin and malt-sugar, or maltose. The 
final product is maltose. 

A large percentage of the sugars ingested with the food is 
lost through fermentation. Lactose is most readily affected by 
the intestinal bacteria, undergoing lactic acid fermentation 
which gives the stool of the breast-fed infant its characteristic 
sour odor. In bottle-fed infants this fermentation is likely to 
exceed the limits which occur in natural feeding and an acid 
diarrhea frequently results from the fermentation of the 
lactose. If the fermentation is not promptly controlled serious 
disturbances may result. Maltose does not ferment as readily 
as lactose while cane-sugar does not undergo lactic acid fermen- 
tation at all. Dextrin and starch exert an inhibiting action 
over intestinal fermentation and are therefore used to "correct" 
this tendency in the bottle-fed infant. High percentages of 
casein in the food also tend to inhibit fermentation. The whey 
of the milk, on the other hand, perhaps due to the presence of 
sodium and potassium salts, intensifies the process. 

The infant presents a higher sugar tolerance than the adult 
and its metabolic needs for carbohydrates are relatively higher. 
Carbohydrates furnish body heat by undergoing combustion 
with the production of carbon dioxide and water. They also 
increase protein metabolism (retention) and are essential to the 
combustion of the fats. When the blood-sugar falls below a 
certain level, products of incomplete fat oxidation appear in 
the blood. These are oxybutyric acid, diacetic acid and acetone. 
A state of acidosis may supervene. Carbohydrate is therefore 
an essential food-stuff and cannot be entirely replaced by protein 
or fat. 



INFANT FEEDING 55 

Gain in weight is more influenced by carbohydrates than 
by any other food-stuff because carbohydrates exert the dual 
role of being eventually converted into fat in the organism if 
taken in sufficient amount and of favoring the retention of water 
in the system. The carbohydrate which is not oxidized is 
deposited in the liver and muscles in the form of glycogen; 
a certain proportion is converted into fat. The chief nutritional 
function of the carbohydrate, however, is to supply heat and 
energy, to spare the body proteins and favor the complete 
combustion of the fats. 

The Mineral Salts in Metabolism. — The mineral salts 
cannot be looked upon in the light of food-stuffs but nevertheless 
their presence in the food in normal amounts is essential to the 
welfare of the organism. Inorganic salts are necessary to 
maintain the normal alkalinity of the blood plasma which is in 
constant danger of being robbed of its alkalinity by the acids 
formed in the body during the metabolism of proteins and fats. 
The growing organism also requires large amounts of calcium 
for the development of the osseous system while iron is needed 
for the blood. As a rule, a sufficient amount of mineral salts 
is found in the food ingested; disturbances in the metabolism 
of these salts result from digestive derangements or from a 
nutritional disorder rather than from a deficient supply. 

Woman's milk contains about 0.2 per cent of mineral salts 
while cow's milk contains about 0.7 per cent. From this it 
will be seen that even when cow's milk is diluted as it usually 
is in infant feeding, the infant receives a little more mineral 
matter in the artificial food than in the woman's milk. 

Sodium chloride promotes the retention of water in the 
system; it is perhaps the most important constituent of the 
blood plasma. The action of potassium is essentially that of 
sodium. Potassium is found freely in all vegetables and fruits 
and the alkalinity of the tissues is largely maintained by the 
salts ingested with the food. 

Calcium is normally retained in the system to supply the 



56 DISEASES OF CHILDREN 

tissues which require it in their growth and metabolism. Under 
some conditions, however, more calcium is excreted from the 
body than is retained and we then speak of a negative calcium 
balance. The chief seat of calcium excretion is the intestine; 
when an acid reaction of the intestinal contents exists the normal 
resorption of calcium is interfered with. This is especially the 
case when the infant is fed with high-fat formulae, the fatty 
acids of the stools combining with the alkaline calcium salts and 
forming an insoluble calcium soap which is excreted by the 
bowels. Calcium deficiency is especially noted in rickets and 
in tetany. Cod liver oil has been shown to increase calcium 
retention in rickets but the question arises whether this effect 
is due to the fat itself or to the presence of a fat-soluble vitamin 
which influences the rachitic process favorably. The unfavor- 
able action of an acid intestinal tract is not limited to a 
disturbance of calcium balance alone. In order to meet the 
abnormal condition resulting from fat overfeeding the intes- 
tinal secretion is augmented and in this manner the system is 
drained of its alkalis. A compensatory increase in ammonia 
production takes place and there is an increased output of 
urinary ammonia. Acidosis may result if the condition is 
not corrected in time. 

ARTIFICIAL FEEDING. 

In looking about for a substitute for breast feeding we 
naturally turn to cow's milk as this is the only fresh milk which 
is commercially available. Proprietary infant foods containing 
milk are made from cow's milk ; those which do not contain milk 
are not complete foods but milk modifiers intended to be added 
to cow's milk either for the purpose of rendering the same more 
digestible, or to add to the food value (carbohydrate) of the 
milk, or for both of these purposes. 

Cow's milk cannot be successfully used as an infant food in 
its natural state ; it must therefore be modified in order to over- 
come certain of its physical and chemical properties. Cow's 



INFANT FEEDING 57 

milk whose composition has been so altered as to conform to the 
digestive function of the infant and to its nutritional needs is 
spoken of as "modified milk." This modification is usually 
accomplished by diluting the milk with water in order to reduce 
the amount of casein present in cow's milk and by the addition 
of sugar (sugar of milk, cane sugar or a proprietary malt sugar 
preparation) to raise the percentage of carbohydrate in the 
mixture. Cream is also added at times and alkalies (lime 
water, bicarbonate of soda) have been used to render the 
food alkaline. 

Cow's milk differs both physically and chemically from 
woman's milk in many important particulars. There is a 
biological reason for this difference (Chapin). The cow is 
herbivorous and its food is digested mainly in the stomach. 
The calf is therefore supplied with a milk which coagulates into 
a tough curd in the stomach and which requires the same 
conditions for its digestion as for the digestion of the food of 
the adult animal. Man in omnivorous and gastric digestion is 
but a preparatory step to intestinal digestion; consequently 
the infant's stomach must receive a food corresponding to a 
thoroughly masticated meal and cow's milk, in order to be 
acceptable, must be modified accordingly. Furthermore, as 
Bunge has shown, the chemical composition of the milk of the 
species corresponds in its protein and mineral salt content with 
the rapidity of growth of the young of the species. The more 
rapid the growth, the higher the content of these elements. The 
infant grows proportionately much slower than most other 
mammals ; consequently woman's milk is poorer in protein and 
mineral salts than cow's milk. 

The following table shows the differences in the percentage 
composition of woman's milk and cow's milk: 

Woman's Milk Cow's Milk 

Fat 3.5 per cent 4 per cent 

Protein 1.5 per cent 3.5 per cent 

Sugar 7.0 per cent 4.5 per cent 

Salts 0.2 per cent 0.75 per cent 



58 DISEASES OF CHILDREN 

A perusal of this table shows at a glance that there is a decided 
difference in the percentages of the components of these two 
types of milk. The fats are about equal but the protein is more 
than twice as high in cow's milk than in woman's milk while 
the percentage of sugar is much lower. It is therefore a reason- 
able procedure to modify the milk of the cow by diluting it with 
water in order to reduce the amount of protein and then add 
sugar to bring this component up to the amount found in 
woman's milk. Some cream must also be added for the purpose 
of restoring the amount of fat which was cut down by the 
dilution of the milk. By this method of modification cow's 
milk can be so changed as to make it correspond approximately 
with woman's milk. Clinical experience, however, has taught 
us that milk thus modified does not always agree with the 
infant's digestion or give the best results from the standpoint of 
gain in weight. As a rule, a young infant requires a weaker 
formula while an older one requires a stronger one. Attempts 
to regulate the percentage of fat, protein and sugar in the food 
according to indications furnished by the infant's digestion, 
stools and gain in weight led to the development of the so-called 
"percentage method" of infant feeding. The percentages of 
fat, protein and sugar found in woman's milk were used as a 
standard and these percentages were varied according to the 
needs of the case. 

Owing to the fact that this method was primarily based upon 
a misconception concerning the digestibility of the casein of the 
cow's milk it has not worked out as well clinically as was 
expected. Experience has taught us that the fat of cow's milk 
causes digestive disturbances more frequently than the casein 
and that artificially fed infants cannot take as high a percentage 
of fat in their food as is found in woman's milk. Dilutions 
of whole milk give better results ordinarily than milk and cream 
mixtures or top-milk dilutions. 

The most important question to determine in artificial feeding 
is the amount of food which the infant requires in twenty-four 



INFANT FEEDING 59 

hours. Any method of feeding to give good results must be 
based on caloric requirements. With this thought in mind the 
so-called "caloric method" has been evolved. 

By the caloric method the amount of food is calculated on 
the basis of the infant's caloric requirements according to its 
age and weight. All that is necessary is to determine the 
number of calories required by the infant in twenty-four hours 
and then compute the amount of milk and sugar necessary to 
furnish these calories. One of the chief advantages of using 
whole milk dilutions as the basis of the milk formula is the 
simplicity of this method of feeding. With proper dilution 
the modification of the milk to suit the infant's digestion is 
usually accomplished with little difficulty. Furthermore, the 
mother or nurse will not be burdened with instructions which 
are difficult for them to understand and with directions requir- 
ing much time and labor so that their many other duties are 
too much interfered with. The importance of avoiding com- 
plicated methods in the home modification of the infant's food 
cannot be exaggerated. It is true, special formulae such as 
top-milk dilutions and milk and cream mixtures are frequently 
required in special instances. However we are likely to see our 
best efforts defeated if we give the mother duties to perform 
which she may not be able to carry out. There are milk 
laboratories in most large cities where special formulae can be 
prepared for those who can afford this luxury and where special 
foods can be obtained if sickness requires their employment. 
The chief dangers, however, of attempting to carry out 
complicated methods in the home are that the food may be 
improperly prepared and that the mother may become dis- 
couraged and turn to the easiest remedy at hand, namely, 
condensed milk or some one of the proprietary foods. 

Caloric Requirements in Infancy. — At birth the infant 
requires 45 calories per pound of body weight. As it grows 
older these requirements gradually fall so that at the end of 
a year it needs about 39 calories per pound of body weight. At 



60 



DISEASES OF CHILDREN 



two years the requirements are about 36 calories; at ten years 
27 and for an adult 20 calories per pound of body weight. 
While the caloric requirements in the normally growing infant 
therefore gradually decrease, the underweight and the premature 
infant on the other hand, require a relatively greater amount 
of food than the normal infant. Such infants may need from 
50 to 60 calories per pound of body weight in order to make 
them gain. Unfortunately the digestion is so weak in these 
cases that unless they can get these calories in the form of 
woman's milk they will be unable to digest the food. We are 
not simply called upon to furnish the infant with the proper 
number of calories but we must give them in the form of a well 
balanced food in which the fat, protein, carbohydrate and 
mineral salts are in a digestible and available form. Further- 
more, the food must also contain the necessary vitamins without 
which normal nutrition and metabolism are impossible. If 
they are not present in the milk in sufficient amount they must 
be supplied from other sources. 

The following table gives in a convenient form the number of 
calories required at the different months and the average weight 
of the infant at these months: 



CALORIC REQUIREMENTS AND WEIGHTS ACCORDING TO AGE. 
7.5 lbs. 45 Calories per lb. Total, 337 C. 



At birth . . . 
1 month . . . 



9.0 



2 mos 11.0 

3 " 12.5 



4 
5 
6 

7 
8 
9 

10 
11 
12 



2 yrs. 



14 
15 
16 

17 
18 
19 

20 
21 
22 

28 



45 

44 
44 

42 
42 
42 

40 
40 
40 

39 
39 
39 

36 



400 C. 

480 C. 
550 C. 

590 C. 
630 C. 
670 C. 

680 C. 
720 C. 
760 C. 

780 C. 
820 C. 
860 C. 

1000 C. 



INFANT FEEDING 61 

The Digestibility of Cow's Milk. — Were it possible for 
the infant to digest and assimilate cow's milk as readily as 
woman's milk artificial feeding would present very few diffi- 
culties. Cow's milk, however, differs from woman's milk not 
only in the proportion of fat, protein and carbohydrate but 
there is also a difference in the digestibility of the fat and 
protein of these milks. Clinical experience has taught us 
that the young infant will not, as a rule, tolerate cow's milk 
unless it has been well diluted. After the infant has taken the 
diluted milk for a time, tolerance is established and the food 
can then be gradually made stronger. We therefore, as a 
rule, begin feeding milk which has been diluted with two parts 
water. After the second month equal parts of milk and water 
are usually well tolerated; from the fifth to the ninth month, 
two parts milk to one part water may be given. 

The Proteins of Cow's Milk. — The principle protein of 
milk is casein. Casein is a nitrogenous compound which is 
insoluble in water and represents about 3 per cent of the milk 
protein. Lact-albumin is another protein found in cow's milk ; 
it is soluble in water and furnishes one-half per cent of the 
proteins. The casein of cow's milk coagulates into a firm curd 
after reaching the stomach through the action of the milk 
curdling ferment in the gastric juice. Mother's milk produces 
a fine, flocculent curd which is readily digestible. The casein 
cannot alone be blamed, however, for the digestive disturbances 
resulting from artificial feeding. The fat and sugar must 
also be taken into consideration. Should casein indigestion 
occur as shown by the vomiting of tough curds or colic with the 
presence of the characteristic tough, bean-like curds in the stools, 
this difficulty can readily be overcome by boiling the milk. 
Boiling the milk has a more marked and more certain effect 
upon the digestibility of casein than such procedures as adding 
a large amount of alkali or such substances as sodium citrate 
to the food mixtures. The beneficial effect of boiling the milk 
can be demonstrated by results seen in cases of dyspepsia and 



62 DISEASES OF CHILDREN 

even in some cases of enteritis if boiled skimmed milk dilutions 
are nsed. The curds and mucus of the stool are promptly 
replaced by a smooth, salve-like residue. 

The Fat of Cow's Milk.— The fat of cow's milk differs 
from that of woman's milk in a higher content of the volatile 
fatty acids which fact is given as one of the explanations for 
its being less digestible. While both cow's milk and woman's 
milk contain approximately the same amount of fat, namely 
4 per cent, nevertheless it is a well established clinical fact that 
the majority of artificially fed infants cannot take this amount 
of fat over a prolonged period of time. It has been found that 
dilutions of whole milk furnish not only a sufficient amount 
but also as much fat as can usually be well borne by the infant. 
As the infant grows older its tolerance for fat increases, just 
as is the case with the casein. 

Fat overfeeding produces vomiting, diarrhea with fat curds 
in the stools, or constipation with large, dry, calcium soap 
stools and eventually metabolic disturbances such as eczema 
and acidosis. The amount of fat entering into the infant's 
diet must therefore always be carefully supervised. 

The Carbohydrate of Milk. — Cow's milk and woman's 
milk both contain lactose, or sugar of milk, as their carbohydrate 
constituent. So far as we know, there is no difference in the 
digestibility or in their chemical behavior. In artificial feed- 
ing, however, we frequently encounter trouble when lactose is 
used as an addition to the milk ; excessive fermentation leading 
to the development of a fermental diarrhea with excoriating 
stools ; excoriated buttocks, fever and loss of weight often result 
from its use. It has also been observed that infants do not, 
as a rule, gain as rapidly when taking milk mixtures containing 
milk sugar as when other sugars are used. Cane sugar is not 
fermented into lactic acid in the intestinal tract and frequently 
agrees better than milk sugar. The popular vogue of condensed 
milk rests partly upon the fact that it contains cane sugar and 
that it is readily digested and is fattening. The most fattening 



INFANT FEEDING 63 

sugar is maltose. Maltose can be fed in larger proportions 
than sugar of milk and the condition of the bowels can be readily 
regulated by means of varying the amount of maltose in the 
food. Maltose is never given in pure form but is combined 
with dextrine. The dextrine is an advantage since it controls 
the laxative action of the maltose to some extent and further- 
more it makes it possible to keep the malt in the form of a 
powder which is not possible with the hygroscopic pure maltose. 
Among the commercial malt preparations available for infant 
feeding Dextrimaltose, Mellin's Food and Borcherdt's malt 
sugar may be mentioned. Cane sugar is the heaviest of the 
sugars, two level tablespoonfuls equaling one ounce by weight. 
Sugar of milk and Dextrimaltose are lighter and require three 
level tablespoonfuls to make an ounce. 

Barley water and other cereal decoctions are frequently used 
as diluents instead of plain water. Barley-water influences the 
digestibility of the casein favorably, overcoming the tendency 
to diarrhea which cow's milk sometimes induces. Oatmeal-water 
is often beneficial in overcoming constipation. Besides these 
physical effects, the cereal decoctions possess slight food value. 

The Quantity of Food Required. — The gastric capacity is 
about one ounce at birth and it increases at the rate of an ounce 
a month. During the first two months, therefore, the infant 
should receive from two to three ounces at a feeding. At three 
months it should receive four ounces and at five months six 
ounces and so on. 

The intervals for feeding should be so regulated that the 
stomach has had time to empty itself before the next meal is 
taken. This requires about three hours for a weak food and 
four hours for a stronger formula. Up to five months, there- 
fore, the infant should be fed every three hours and after that 
time every four hours. The proper dilution of the milk, the 
amount for each feeding and the interval between feedings may 
be summed up as follows : 



64 



DISEASES OF CHILDREN 



1 mo. J milk, 

2 mo. imilk, 

3 mo. I milk, 

4 mo. J milk, 

5 mo. § milk, 

6 mo. § milk, 
7-8 mo. § milk, 

9 mo. | milk, 
10-11 mo. gmilk, 



§ water, 
1 water, 
1 water, 
J water, 
| water, 
I water, 
| water, 
I water, 
I water, 



I oz. sugar 
lj oz. sugar 

II oz. sugar 
11 oz. sugar 
11 oz. sugar 
1J oz. sugar 
11 oz. sugar 
1 oz. sugar 
1 oz. sugar 



2 oz. 3 hours; 

3 oz. 3 hours; 
4oz. 3 hours; 

5 oz. 3 hours; 

6 oz. 3 hours; 

7 oz. 4 hours; 

8 oz. 4 hours; 

9 oz. 4 hours; 
10 oz. 4 hours; 



bottles in 24 hrs. 



« (( 


" " 


«< (( 


(( <( 


«« (< 


(( (( 


« 


(( « 


(( (( 


« « 


<( <( 


(< <( 


« « 


(« << 



12 mo. whole milk, 10 oz. at a feeding 



During the first month an infant requires from eight to ten 
ounces of milk and one ounce of sugar to meet its caloric 
requirements. From the second to the fourth month it needs 
about one pint of milk and one and a half ounces of sugar. 
From the fifth to the seventh month twenty-four ounces of milk 
and one and a half ounces of sugar will be needed. During the 
eighth and ninth months it will need twenty-eight ounces of 
milk and one ounce of sugar. The following table gives the 
formulae which we have used for some time at the Mothers' 
Clinic at the Hahnemann Hospital. Owing to their simplicity 
and their applicability to the average normal case they can 
safely be recommended for general use. 



1 to 2 mos. . .3 ounces every 3 hours. . .7 bottles in 24 hours. 

Formula: Milk, 8 oz.; water, 12 oz.; sugar, 1 oz.; or 

2 level tablespoons. 

3 mos 4 ounces every 3 hours. . .7 bottles in 24 hours. 

4 mos 5 ounces every 3 hours. . .6 bottles in 24 hours. 

Formula: Milk, 1 pint; water, 14 oz.; sugar, 11 oz.; or 
3 level tablespoons. 

5 mos 6 ounces every 4 hours. . .5 bottles in 24 hours. 

6 & 7 mos.. .7 ounces every 4 hours. . .5 bottles in 24 hours. 

Formula: Milk, 24 oz.; barley water, 12 oz.; sugar, 11 
oz.; or 3 level tablespoons. 

8 mos 8 ounces every 4 hours. . .5 bottles in 24 hours. 

9 mos 9 ounces every 4 hours. . .5 bottles in 24 hours. 

Formula: Milk, 32 oz.; barley water, 12 oz.; sugar, 1 
oz.; or 2 level tablespoons. 



INFANT FEEDING 65 

Top-Milk Dilutions. — Infants that do not gain satisfactorily 
upon whole milk dilutions are sometimes benefited by a change 
to top-milk. The advantages of top-milk are its high caloric 
value and its laxative effect in certain cases of constipation. 
Before resorting to top-milk, however, we must first satisfy 
ourselves that the infant is capable of digesting a high-fat 
formula. If there has been much spitting up or vomiting the 
additional cream in the formula will most likely aggravate the 
symptoms. If the infant is suffering with constipation the 
stool should be examined according to the method previously 
described. If the constipation is due to the presence of calcium 
soap in excess in the stool the addition of fat to the formula 
will only aggravate the condition. This type of constipation 
calls for a still further reduction in the fat and an increase in 
the carbohydrate. 

Top-milk dilutions are sometimes better tolerated than whole 
milk mixtures of equal caloric value owing to the fact that the 
ratio of casein to fat is decidedly lower than in whole milk. 
Most infants can take a fairly high percentage of either fat or 
protein provided both of these elements are not present in the 
food in high percentages at the same time. Most infants can 
digest undiluted skimmed milk ; if, however, the fat is restored 
to the milk the food becomes too rich for the infant. The same 
holds good with the protein. When the protein is reduced the 
fat may be proportionately increased. In whole milk the ratio 
of fat to protein is 1:1, in a ten per cent top-milk it is 3 :1, 
and in a seven per cent top-milk 2 :1. Top-milk must be given 
in more dilute form than whole milk and so the percentage of 
protein is low in these formulae. 

One ounce of ten per cent top-milk has a food value of 38 
calories. When diluted with two parts water this is reduced 
to 13 calories. One ounce of whole milk has a food value of 
21 calories; the above dilution reduces this to 7 calories. Whole 
milk formulae therefore require a much larger proportion of 
milk than do top-milk formulae. 
6 



66 DISEASES OF CHILDREN 

If a quart of milk be permitted to stand from four to five 
hours practically all of the cream will have risen to the top of 
the bottle at the end of that time. The upper layers of the 
cream are the richest in fat and if we remove the upper ten 
ounces from the quart with a Chapin dipper or by carefully 
decanting the same into a measuring glass we will obtain a 
mixture of milk and cream containing approximately 10 per 
cent of fat and 3.5 per cent of protein. This is spoken of as 
"ten per cent top-milk." By removing the upper sixteen ounces 
from a quart of set milk we obtain a milk and cream mixture 
containing approximately 7 per cent fat and 3.5 per cent protein. 
This is called "seven per cent top-milk." 

Ten per cent top-milk is rarely used because of its high fat 
content and it must be diluted with at least two parts of water 
before it can be fed to the average baby. A formula of one 
part ten per cent top-milk, two parts water and ^.ve per cent 
sugar contains approximately 3% per cent fat, 1.2 per cent 
protein and 6.5 per cent sugar. This formula corresponds to 
the percentage composition of woman's milk in the early period 
of lactation. Unfortunately, however, such a formula will not 
take the place of breast milk with a young infant with feeble 
digestion. 

Seven per cent top-milk when diluted with two parts water 
gives a formula containing 2% per cent fat and 1.2 per cent 
protein. This amount of fat is more likely to agree with a 
young or delicate infant and this formula is therefore valuable 
when a relatively high fat per cent and a relatively low protein 
per cent are indicated. When diluted with an equal part of 
water seven per cent top-milk gives a formula containing 3% 
per cent fat and 1% per cent protein. This is a useful formula 
for an infant from three to six months old with normal digestion 
or for the correction of simple constipation. The formula 
closely approximates woman's milk in the latter period of 
lactation and is a good "imitation" of breast milk. Five per 
cent of sugar must be added in order to bring the sugar percent- 
age up to seven per cent. 



INFANT FEEDING 67 

Method of Calculating the Ingredients in the Food. — 

Having determined the number of calories required by the 
infant in twenty-four hours according to the rules given above 
(see table, page 60), the amount of milk and sugar that will be 
needed to furnish the specified number of calories in the formula 
must next be calculated. A good general rule for determining 
the amount of milk is to allow one and one half ounces per 
pound of body weight. This will supply the adequate amount 
of protein to cover the child's nutritional needs (Holt). The 
remaining calories will be furnished by the sugar entering into 
the formula. The water in the formula must be sufficient to 
make up the amount of food required in twenty-four hours. 
The following example should make these directions clear : An 
infant four months old weighing 14 pounds and requiring 42 
calories per pound will need a formula furnishing approximately 
590 calories. If one and one half ounces of milk per pound of 
body weight are allowed in our calculation then 19 ounces of 
milk will enter into the formula. This amount if milk will 
furnish 380 calories (one ounce of milk equals 20 calories). 
Subtracting 380 from 590, the total number of calories required, 
we have a deficiency of 210 calories. The latter must be made 
up by the sugar of the formula. One ounce of sugar has a food 
value of 120 calories, therefore it will require one and three 
quarter ounces of sugar to furnish the remaining 210 calories. 

Having fixed the amount of food stuffs entering into the 
formula we must next determine the amount of water. Water 
must be added in sufficient amount to make the proper quantity 
of food for twenty-four hours. The infant's age decides this 
question. At four months the average capacity of the stomach 
is five ounces ; the infant should receive six bottles at three hour 
intervals. The amount required in twenty-four hours is there- 
fore thirty ounces. Since nineteen ounces of milk enter into 
the formula a balance of eleven ounces of water is needed to 
make up the deficit. The formula now reads as follows: 19 
ounces milk, 11 ounces water, 1% ounces sugar. Divide into 
6 bottles of 5 ounces each; feed every 3 hours. 



68 DISEASES OF CHILDREN 

Another method recommended is to fix a definite amount of 
sugar for the formula based upon the infant's age or weight. 
Clinical experience has taught us that the normal infant from 
one to two months old, or an infant under ten pounds weight, 
requires one ounce of sugar in twenty-four hours. From the 
third to the sixth month it needs one and one half ounces. 
Perhaps more accurately stated we should allow five per cent 
of sugar added to the formula; in other words, for a twenty 
ounce formula, one ounce of sugar ; for a thirty ounce formula, 
one and one half ounces of sugar and for a forty ounce formula, 
two ounces of sugar. Consequently, if we know the amount of 
food required in twenty-four hours we can first determine the 
amount of sugar entering into the formula, compute its caloric 
value, subtract this from the total number of calories needed 
and make up the balance with milk, allowing 20 calories per 
ounce of milk. The result in the above cited case would be 
slightly different because we would allow only one and one half 
ounces of sugar (five per cent of thirty ounces) which would 
furnish 180 calories. In order to supply the remaining 410 
calories we would have to use 20% ounces of milk. Absolute 
mathematical accuracy in the making of these formulae is un- 
necessary, however, and if we gave directions for using 20 
ounces of milk, one and one half ounces of sugar and 10 ounces 
of water we would come near enough to the mark for all 
clinical purposes. 

Method of Estimating Percentages in a Milk For- 
mula. — The percentage of fat and protein in a milk formula 
can readily be calculated from the number of ounces of milk, 
cream or top-milk entering into the formula. We must, of 
course, know the percentage of fat in the milk, cream or top-milk 
used in the formula. The following rule is a simple method 
for obtaining the above data : "Multiply the percentage of the 
ingredients entering into the the formula by the number of 
ounces of the same used in the formula and divide the product 
by the total number of ounces in the formula." For- example, 



INFANT FEEDING 



given a formula containing 10 ounces of 7 per cent top-milk 
and 10 ounces of water, the percentage of fat and protein are 
calculated as follows: 7 per cent top-milk contains 7 per cent 
fat and 3.4 per cent protein. The percentage of fat in the 
formula is: 7 x 10 divided by 20 equals 3.5 per cent. The 
percentage of protein is: 3.5x10 divided by 20 equals 1.75 
per cent. 

Method of Estimating the Number of Calories in a 
Milk Formula. — The caloric value of a food can be estimated 
directly from the percentage of fat, protein and carbohydrate 
which it contains, remembering that one gram of fat furnishes 
9.3 calories and one gram of protein and one of carbohydrate 
furnish 4.1 calories respectively. Fraley has devised a simple 
formula for making these estimations which gives the caloric 
value of the food per ounce. "Multiply the percentage of fat 
by two, add the sugar percentage and the protein percentage and 
multiply the result by 1.3." To illustrate, we will apply this 
rule in the case of cow's milk. The food value of cow's milk 
is usually given as 21 calories per ounce. Its percentage 
composition is 4 per cent fat, 3.5 per cent protein and 4.5 per 
cent sugar. Therefore, 8 plus 3.5 plus 4.5 equals 20.8 C. 

The most practical method, however, of estimating the food 
value of a formula is to compute the same directly from the 
ingredients entering into the formula. Since the food value of 
an ounce of cow's milk is 21 calories and that of an ounce of 
sugar is 120 calories the number of ounces of milk and sugar 
entering into the formula represents the caloric value of the 
food. Similarly, if top-milk or cream be used, the calories can 
be calculated on the same basis (see table, page 50). 

The Use of Lime Water and Other Alkalies. — The 
addition of lime water and other alkalies to the infant's food 
is frequently recommended. This procedure, however, is based 
upon a misconception concerning the digestibility of the casein 
of cow's milk and also upon the erroneous belief that while 
mother's milk was alkaline in reaction, the milk of the cow was 



70 DISEASES OF CHILDREN 

acid in reaction and should therefore be rendered alkaline. 
Theoretically, the coagulation of cow's milk in the infant's 
stomach can be delayed or even prevented by the use of alkalies. 
This, however, is not a desirable result to be obtained. The 
acidity of the gastric contents is a prerequisite to normal 
digestion (see ante). Furthermore, should the casein of the 
cow's milk cause digestive disturbances these can be overcome 
much more satisfactorily by boiling the milk than by the 
addition of alkalies to the food. The use of lime water for 
the purpose of adding calcium to the food is illogical because 
the casein of cow's milk contains more than enough calcium 
to supply the metabolic needs of the infant. 

Pasteurization : Boiled Milk. — The question whether milk 
should be fed in its raw state or whether it should be sterilized 
by means of pasteurization or boiling depends upon circum- 
stances. Naturally it would seem most logical to employ raw 
milk, with its vitamins and ferments intact, rather than give the 
infant a "dead," sterilized food. Raw milk, however, is a 
dangerous bacteria carrier and it is therefore safe to use it in 
the raw state only if it is known to come from absolutely healthy 
cows and milked and bottled under the strictest sanitary pre- 
cautions. These requirements are fulfilled in the case of 
"certified" milk and such milk is safe in so far as its bacterio- 
logical standing is concerned. Raw milk, however, is at times 
not well digested and in such cases it should be boiled for the 
purpose of changing the physical character of the casein. Raw 
milk forms a more or less tough, firm curd in the stomach while 
boiled milk yields a softer, more digestible curd. Boiling the 
food, therefore, must be considered from the standpoint of its 
effect upon the digestion as well as a safe and simple method 
of sterilization. 

Pasteurization does not alter the taste nor the digestibility 
of the milk as does boiling. Commercially pasteurized milk 
is not altogether safe from the bacteriological standpoint. All 
ordinary dairy milk, therefore, should be pasteurized before 



INFANT FEEDING 71 

being given to the infant. This is best done by pasteurizing 
the food directly in the bottles after the formula has been made 
up. The Freeman Pasteurizer is a convenient apparatus for 
this purpose. If a pasteurizer is not available the filled bottles, 
stoppered with pledgets of cotton, should be immersed in a 
pail or dish-pan filled with water up to the level of the food in 
the bottles. The water is slowly heated to 160 degrees F. and 
then the pan is taken from the fire and covered with a heavy 
cloth to prevent too rapid cooling of the water. At the end of 
thirty minutes the bottles are rapidly cooled in running water 
and kept on ice. 

It has been urged that pasteurized milk has all the advantages 
of raw milk while there is not the danger of scurvy and rickets 
developing with its use as is the case when boiled milk is fed 
over a prolonged period of time. This assertion, however, lacks 
clinical proof. Scurvy and rickets do not develop solely from 
boiling the milk. Furthermore, when artificial foods are used 
the child should early receive orange juice and vegetable broths. 
When this is carried out there is no danger, per se, from boiled 
milk. Boiling the milk is a simple and surer method of sterili- 
zation than pasteurization. 

The Preparation of the Food. — The utensils that will be 
required for the preparation of the infant's food are : an agate- 
ware saucepan holding two quarts, for mixing the food; a 
double boiler, for preparing barley-water and other similar 
preparations; a large kitchen spoon for stirring the food; a 
sixteen ounce glass graduate; a pitcher and a funnel. It is 
wise to keep these utensils exclusively for the baby's diet kitchen. 

Since the total amount of food for the twenty-four hours is 
made up each morning there should be on hand a sufficient 
number of bottles and a wire bottle rack so that the proper 
amount of food can be put into each bottle and the bottles 
immediately placed on ice. In selecting a bottle the main 
point to bear in mind is the cleaning of the same ; round bottles 
with a fairly wide neck into which a bottle brush can readily 



72 DISEASES OF CHILDREN 

be introduced are the preferable pattern. An infant under 
four months old requires a bottle holding six ounces ; up to six 
months an eight ounce bottle and after that time a ten or twelve 
ounce bottle. If we allow for an empty space of an ounce or 
two in the bottle the infant will be better able to nurse than if 
the bottle is filled up to the neck. 

The best nipples are those which do not readily collapse and 
which can be inverted so that they can be thoroughly scrubbed 
and rinsed. 

All instructions for preparing the infant's food should be 
given in writing. Many serious errors in the preparation of the 
food are made through a lack of proper instruction or through 
a misunderstanding on the part of the mother. When raw 
milk is to be used in the formula it is most important that the 
sugar be first dissolved in warm water and the solution be 
allowed to cool before milk is added. The milk should never 
be permitted to become warm excepting just before feeding 
the baby when it must be warmed to blood heat by placing the 
bottle in a saucepan of hot water. 

The author makes it a practice of supplying his patients with 
a feeding-blank, properly filled out, which gives instructions 
for preparing the formula as well as indicating the proper 
amount of each ingredient. Patients are instructed to report 
at regular intervals so that the baby's progress in weight and the 
state of its digestion can be followed. With each report a 
specimen of the baby's stool should be brought for inspection and 
chemical examination if necessary. 

All bottle-fed infants should receive orange juice after the 
fourth month. This may be given in doses of a teaspoonful 
gradually increased to three or four teaspoonfuls diluted with 
an equal amount of water. The best time to give the orange 
juice is one hour before feeding. 



INFANT FEEDING 73 

Milk quart, pint, ounces 

Top milk (upper . . . .oz. from a quart) ounces 

Cream ounces 

Water, barley-water ounces 

Sugar, or food level tablespoonfuls. 

Directions: (a) Boil some water for five minutes, take from fire 

and measure out the amount specified above. Add the to 

the water, dissolve thoroughly and let the solution get cold. Then add 
the milk, which should be ice cold, mix thoroughly by stirring with a 

large spoon and fill the bottles, pouring ounces into each 

of bottles. Stopper the bottles with pledgets of sterile 

cotton and put on ice immediately. 

(b) When the food is to be boiled prepare as follows: 

Mix the milk and water and boil for three minutes, constantly 
stirring to prevent the formation of a scum. Take from the fire and 
add the sugar, or food. Fill the bottles, cool rapidly in running water 
and put on ice. 

Feeding Schedule: oz. every . . .hours . . .A. M. . . .P. M. 

Always use a fresh, unopened bottle of milk for the baby's formula. 

Empty the nursing bottle immediately after each nursing, scrub 
with a bottle brush, using warm soap-suds, then rinse with plain warm 
water. Boil the bottles every morning before filling. 

The nipples should be rinsed after each feeding, turned inside 
out to thoroughly cleanse them, boiled for five minutes, rapidly dried 
and then kept in a sterile fruit jar, or a jelly glass with a tight fitting 
cover. 

Barley water is prepared as follows: Take one level tablespoonful 
of barley flour and blend into a thin smooth paste with a little cold 
water. Pour into a pint of boiling water containing a pinch of salt. 
Boil slowly in an open saucepan for five minutes, stirring occasionally, 
then transfer to a double boiler, cover and cook for twenty minutes. 
Strain, and add sufficient water to make one pint. 

FEEDING DURING THE SECOND YEAR. 

When the infant is a year old it should be able to take milk 
in its natural state, that is, without the addition of water or 
sugar. Some infants, however, have an abnormally low tol- 
erance for cow's milk and in such cases it may be necessary to 
still remove part of the cream or add water to the milk even 
after they have attained this age. Other foods, notably cereals 



74 DISEASES OF CHILDREN 

and green vegetables, properly prepared, should now form an 
important part of the dietary and the child should be weaned 
from its bottle. 

Cereals must be thoroughly cooked; a convenient way of 
preparing them is to let them cook in a tireless cooker over night 
so that they will be ready early in the morning. The uncooked 
cereals are not suitable for children. 

Vegetables should first be added to the diet in the form of a 
vegetable soup. This contains the mineral salts and vitamins 
so essential to the child's normal growth and is also an excellent 
food to correct constipation. Older children may have any of 
the tender fresh vegetables, well cooked and mashed. Baked 
potato and boiled rice may be given at one year of age. 

Bread and Zwieback can be given as the molar teeth appear. 
Butler is often digested better than cream and may be used 
on cereals and vegetables when cream disagrees. 

Eggs are rich in fat and iron and also contain the fat-soluble 
vitamin. They are therefore a most important food and should 
be gradually introduced into the child's diet. They are best 
given cautiously as many children show evidence of anaphylaxis 
to egg albumin. 

Meat is not required until the latter part of the second year 
at which time it may be given several times a week. There is 
no especial preference as to the kind of meat so long as it is 
fresh and tender. Older children may have meat once a day. 
For a young child it should be minced or cut very fine. 

Desserts. The best desserts for children are the simple milk 
puddings and custard. The latter may be used for introducing 
eggs into the child's diet and in place of a meat course in the 
meal. Gelatine, on account of its high lime content, may 
occasionally be given. Fruit is best given stewed and makes 
an excellent dessert especially in conjunction with a meat menu. 
Bananas have a high food value but their starch content makes 
them rather indigestible; they are therefore best given baked. 
A banana can be baked like a sweet potato, in from ten to 



INFANT FEEDING 



75 



fifteen minutes. Peaches, if thoroughly ripe, may usually be 
given raw (pealed). 

The following diet lists will be found applicable for the 
average normal child of the ages specified. 

DIET FOR A CHILD 1 YEAR TO 18 MONTHS 
7 A. M. Half a teacup of cream of wheat or strained oatmeal with 
two ounces of warm milk and a teaspoonful of sugar; six 
ounces of warm milk. 
9 A. M. Juice of half an orange. 
11 A. M. Ten ounces of warm milk from a bottle. Sleep until 1.30 

P. M. 
2 P. M.(a) A cup of strained vegetable soup; a small baked potato; 
cup custard or junket; a slice of stale bread with butter 
or home-made fruit jelly, or 
(&) One ounce of beef juice poured over a slice of bread or 
mixed with half a small baked potato; a tablespoonful of 
strained green vegetable (spinach, string beans, peas, car- 
rots, asparagus tips, stewed celery) ; the pulp of three or 
four stewed prunes, or a small baked apple, or 
(c) A cup of cream soup, or broth with rice, a tablespoonful 
of green vegetable, stewed fruit as above, a thin slice of 
stale bread with butter. 

6 P. M. Boiled rice or a cooked cereal with warm milk, the same 

quantities as at 7 A. M., six ounces of warm milk from a 
cup. 

DIET FOR A CHILD 18 MONTHS TO 2 YEARS 

7 A. M. A teacupful of cooked cereal with warm milk and a tea- 

spoonful of sugar (oatmeal, cream of wheat, wheatena, 
wheaten grits, Petti John's cream of barley) ; one egg, soft 
boiled or coddled; bread and butter; a cup of warm milk. 
11 A. M. Eight ounces of warm milk from a cup. Sleep until 1.30 
P. M. 
2 P. M. Give the following combinations on successive days: 

(a) Eight ounces of strained vegetable soup; a tablespoonful 
of minced white meat of chicken; bread and butter or bread 
and jelly; junket or gelatine. 

(&) Two to three tablespoonfuls of a strained green vegetable, 
such as spinach, carrots, squash, peas, string beans, tender 
lima beans, asparagus tips, stewed celery; two tablespoon- 
fuls of a starchy vegetable, as rice or macaroni or mashed 



76 DISEASES OF CHILDREN 

potato; a tablespoonfull of minced lamb; four ounces apple 
tapioca pudding or a baked apple, 
(c) A medium sized baked potato with butter or beef juice; a 
green vegetable as above; a cup of warm milk; bread and 
butter; a cup custard or bread pudding. 
6 P. M. A teacupful boiled rice or a cereal with warm milk or milk 
toast; a cup of milk or cocoa; bread and butter; fruit jelly 
or jam or stewed fruit. 

DIET FOR A CHILD 3 YEARS AND OVER. 

There should be three meals a day. A child of three years of 
age requires about 1500 calories in 24 hours. The table given 
on page 51 will be found helpful in computing the caloric 
value of the foods commonly entering into the child's diet. A 
glass of milk, or milk and crackers, may occasionally be given 
between meals in the case of very active children who are always 
hungry or in cases of children with poor appetites who, under 
no circumstances, will eat a sufficient amount of solid food at 
their meals. 

Breakfast should consist of a cooked cereal, a soft-boiled or 
poached egg, bread and butter and a cup of warm milk. 

Dinner may be arranged according to the schedule for a two 
year old child excepting that the quantities must be larger and 
there is no necessity for straining the vegetables. It is better 
to give the child its heaviest meal in the middle of the day and 
give a light supper consisting of a cooked cereal or rice; bread 
and butter, a cup of cocoa and some stewed fruit. Three to 
four glasses of milk should be taken daily as this is still the 
most important food for the growing child. When, however, 
a child refuses to eat sufficient solid food it is necessary to 
reduce the milk in the diet until this error is corrected. 

Forbidden Foods. — Candy usually heads the list of forbid- 
den articles of diet. Children are better off without candy and 
should not be encouraged to develop the candy-eating habit. 
However, the craving for sweets is a perfectly natural one in 
the growing child which requires a high-caloric diet and sugar 
furnishes a food of high caloric value. A piece of pure candy 



INFANT FEEDING 77 

after a meal can do no harm. The craving for candy can 
largely be overcome by giving the child plenty of fruit and a 
sufficient amount of sugar in its diet (on cereals and in desserts). 

Meat. — All fried meats; dried beef; kidneys; pork (ex- 
cepting bacon) ; sausage; duck and goose; warmed-over meats. 

Vegetables. — Fried vegetables; cabbage; green corn; cucum- 
bers and pickles ; all raw vegetables. 

Bread and Cake. — Hot bread; griddle cakes; heavy cakes 
like chocolate cake and fruit cake. 

Desserts. — Store candy; nuts; pie; raw fruit and bananas 
excepting as above. 

SPECIAL FOODS AND PROPRIETARY FOODS. 

Barley-Water is a valuable food for temporary use during 
acute illnesses especially when diarrhea is present. It is also 
used frequently as a diluent for cow's milk, and is the best 
form of starch to introduce into the infant's diet. Barley-water 
may be prepared from the grain or more quickly from the flour. 

When made from the grain two tablespoonfuls of barley, 
previously washed, are cooked with a pint of water and a pinch 
of salt for two hours and then strained. Water should be added 
to keep up to one pint. 

To make barley water from the flour take one level tablespoon- 
ful of barley-flour and blend into a thin paste with a little cold 
water. Pour into a pint of boiling water containing a pinch 
of salt. Boil slowly in an open saucepan for five minutes, 
stirring occasionally, then transfer to a double boiler, cover, and 
cook twenty minutes. Strain, and add sufficient water to make 
one pint. 

Albumin Water. — This is a useful preparation in cases of 
vomiting. It is made by taking the white of one egg, placing 
the same in a saucer and cutting it up with a clean pair of 
scissors, then stirring it into a glass of ice cold water, mix 
thoroughly and strain. A pinch of salt and a little sugar may 
usually be added. 



78 DISEASES OF CHILDREN 

Whey. — Take on© quart of milk, warm to 100° F. to 
105° F. and add one tablespoonful essence of pepsin. Let it 
stand half an hour, then pour into a cheese-cloth bag and let 
the whey drip off. 

Beef-Juice. — The most palatable preparation is made by 
slightly boiling a piece of lean beef and then squeezing out the 
juice with a meat press or a potato ricer. It should be served 
warm with a pinch of salt or poured over bread or baked potato. 
Vegetable Soup. — Take one pound of meat (knuckle of 
veal or neck of lamb), let it stand in one quart of cold water 1 
hour. Bring to boiling point slowly and let simmer one hour. Let 
stand until cold and remove all particles of fat. Then add one 
medium sized potato, diced ; one carrot, diced ; one tablespoonful 
of rice, one slice of onion and a teaspoonful of salt. Cook 
slowly one hour. Mash through colander. 

Albumin Milk. — Take one quart of whole milk, heat to 
100° F. and add two teaspoonfuls essence of pepsin or a junket 
tablet previously dissolved in a little water. Let it stand one 
hour, then hang in a cheese-cloth bag for one hour to drain off the 
whey. Place the curd in a fine wire sieve and rub through with 
a pint of buttermilk, repeating this process three times. The 
resulting product is a thin, gruel-like mixture of finely divided 
curds suspended in the buttermilk. It should be kept in a glass 
jar on ice and thoroughly stirred before using. It should be 
fed lukewarm; heat causes it to coagulate. 

Keller s Malt Soup. — Dissolve 2% ounces by measure or 
4 tablespoonfuls of Malt Soup Extract in 22 ounces of warm 
water. 

Dissolve 2% ounces by measure or 5% level tablespoonfuls 
of wheat flour in 11 ounces of milk and strain through a sieve. 

Mix all together and bring slowly to a boil over a slow fire or 
in a double boiler, stirring repeatedly, and boil 5 minutes. 

Proprietary Foods. — A number of artificial infant foods 
are proprietary preparations which are largely advertised, some 
to laity, others to the profession exclusively. Many of these are 



INFANT FEEDING 79 

of practical use to the physician because they meet the demands 
for certain food-stuffs which can be employed advantageously 
in infant feeding. There is no doubt that much harm is fre- 
quently done by the ill advised use of proprietary foods 
especially when they are given over a long period of time and 
without professional supervision. It is therefore important 
for the physician to know the composition of the various 
artificial foods on the market in order that he may judge their 
merits or shortcomings without prejudice. 

Proprietary foods may be classified as those which serve 
merely as milk modifiers, supplying the deficiency of carbo- 
hydrate of cow's milk, e. g., Mead's Dextri-Maltose; Mellin's 
Food ; or those which accomplish a partial digestion of the milk 
through the presence of a digestive ferment (Peptogenic Pow- 
der; Benger's Food). Again others are complete foods, 
requiring only the addition of water in their preparation 
( Nestle' s Food; Condensed Milk). The latter are useful in 
cases of emergency or when fresh milk cannot be obtained ; they 
should never be used over a prolonged period. 

The following list gives a description of the better known 
proprietary foods together with their percentage composition. 

Robinson s Patent Barley-Flour; Brooks' Baby Barley. — 
Barley flour contains about 8 per cent protein. It is 
used for preparing barley-water which enters so largely into the 
composition of modified milk formulae. Barley-water as or- 
dinarily prepared contains about 1 per cent starch and has a 
food value of approximately 2 calories per ounce. 

Mead's Dextri-Maltose. — This is a product of dextrin and 
maltose in about equal parts, resulting from the action of 
diastase upon the starch. It is a pure soluble carbohydrate in- 
tended solely to supplement the carbohydrate deficiency of cow's 
milk. Dextri-Maltose is put up in two forms, No. 1 and No. 2, 
the former contains salt which is a desirable addition to most 
milk dilutions. According to the manufacturers the compo- 
sition of Dextri-Maltose No. 1 is 51 per cent maltose, 42 per 



80 DISEASES OF CHILDREN 

cent dextrin, 2 per cent sodium chlorid. The food value is 
given as 120 calories per ounce. It is manufactured by Mead 
Johnson & Co. 

Mellins Food. — Mellin's food is a maltose and dextrin 
preparation made from wheat and malted barley by the Leibig 
process. It is freely soluble in water and contains approxi- 
mately 59 per cent maltose, 21 per cent dextrin, 10 per cent 
protein and 2.5 per cent potassium carbonate artificially added. 
The caloric value is given as 105 calories per ounce. 

Eskay's Food. — -This food is composed of a mixture of 
barley, wheat and oats, thoroughly baked, with the addition of 
54 per cent sugar of milk and some whole egg. The food is 
prepared by cooking the same with water and adding the 
decoction thus derived to fresh milk. The caloric value is given 
as 120 calories per ounce, dry. It is manufactured by Smith, 
Kline & French Co. 

Nestle's Food. — This food consists of a mixture of cow's 
milk evaporated to dryness with cane sugar and ground 
wheaten biscuit. It is prepared by the addition of water only. 
It is poor in fat and contains a total of 74 per cent carbo- 
hydrates. 

Horlick's Malted Milk. — Malted milk is a preparation 
containing whole milk and the extracts of malted barley and 
wheat evaporated to dryness and converted into a powder. It 
is a complete food requiring the addition of water only. Hor- 
lick's Malted Milk contains 8.78 per cent fat, 16.35 per cent 
protein, 18.8 per cent dextrin, 10.65 per cent lactose, 38.5 per 
cent maltose, 3.86 per cent salts. The caloric value is given 
as 121 calories per ounce. 

Condensed Milk. — Eagle Brand condensed milk, made by 
Borden's Condensed Milk Co., consists of cow's milk evaporated 
at a temperature of 212 degrees Fahrenheit to about one quarter 
its original bulk with the addition of cane sugar. A number 
of other similar preparations are on the market. Its com- 
position is given by the manufacturer as follows: 9.5 per cent 



INFANT FEEDING 81 

fat, 7.84 per cent protein, 53.67 per cent sugar. Its food value 
is 130.6 calories per ounce. 

One part of condensed milk to eight parts of water gives a 
mixture containing 1.33 per cent fat, 1.09 per cent protein 
and 7.48 per cent carbohydrates. The objection to such a 
formula is the high carbohydrate and the low fat and pro- 
tein content. 

Unsweetened Condensed Milk is prepared from whole 
milk without the addition of sugar. It is not as concentrated 
as the sweetened variety and requires less dilution. Sugar or 
malt preparations may be added to the dilutions as in the case 
of fresh milk. 

Dry Milk Preparations. — Recently dried milk has been 
commercialized and certain preparations have been especially 
advocated as infant foods. Mammala is sold as an infant food, 
being a mixture of dry milk and milk sugar (total amount of 
sugar of milk, 54 per cent) . Dryco Brand of dry milk is made 
from milk from which part of the fat has been removed but no 
sugar has been added. Dry milk often agrees with infants who 
cannot take plain milk and is an excellent food to use in travel- 
ing and whenever it is impossible to obtain good, fresh milk. 
When one part by weight of Dryco is mixed with eight parts 
water (one level tablespoonful to one ounce of water), the follow- 
ing strength of food is obtained, 4 per cent protein, 1.5 per cent 
fat, 5.5 per cent sugar of milk. One level tablespoonful of 
Dryco has a food value of 16 calories. 

Peptogenic Powder, manufactured by Fairchild Bros, and 
Foster, is a mixture of sugar of milk with pancreatic extract and 
bicarbonate of soda. By adding this powder to milk dilutions 
and warming the same to blood heat for 8 minutes the casein 
of the milk is partially predigested and the deficiency in carbo- 
hydrates of the cow's milk is overcome. Bengers Food is a 
farinaceous food containing pancreatic extract. It is prepared 
by mixing the food with a little cold milk, then adding 
the balance of the milk and water, boiling hot, and allowing 



82 DISEASES OF CHILDREN 

the mixture to stand for 15 minutes. During this time the 
starch and casein are partially digested. Predigested foods are 
useful in acute digestive disturbances or for temporary use in 
cases of feeble digestion but they should not be used over a 
prolonged period. 

Malt Soup Extracts. — Borcherdt's Malt Soup-Extract and 
Maltine Malt Soup-Extract are preparations of malt syrup to 
which potassium carbonate has been added. They are used in the 
preparation of Keller's Malt Soup which is an excellent food 
in cases of obstinate constipation and in malnutrition and maras- 
mus resulting from overfeeding. The formula made according to 
Keller contains low fat and protein and high carbohydrate 
percentages. 



CHAPTER V. 

DISEASES OF THE NEWBORN. 

CONGENITAL DEFECTS. 

Congenital heart disease, congenital defects of the brain 
resulting in idiocy, and hypertrophic pyloric stenosis are 
the developmental defects of especial interest to the pediatrist. 
Their discussion will be found in the chapters dealing with the 
diseases of those organs. Other defects encountered in the 
newborn are mainly of surgical and obstetrical interest. As- 
phyxia neonatorum and still-birth frequently result from some 
congenital malformation and should therefore always be sus- 
pected in such cases. 

ASPHYXIA. 

Asphyxia in the newborn may be of intra- or extra-uterine 
origin. Intra-uterine asphyxia results from the interruption 
of the placental circulation through compression of the cord 
or premature separation of the placenta. Respiratory efforts 
are excited in the child through the resulting carbonization of 
the blood and the lungs consequently become filled with amni- 
otic fluid. 

Extra-uterine asphyxia occurs at the time of or shortly after 
birth. The degree of asphyxia may be of different grades, 
varying from a simple interference with the respiratory func- 
tion from the aspiration of mucus or amniotic fluid into the 
upper respiratory tract to a complete cessation of respiration. 
In the latter case the child may be robust when born and present 
all of the signs of active asphyxia, the body surface being 
cyanotic and the face bloated (sthenic asphyxia) ; or it may be 
pallid and limp and apparently lifeless (asthenic asphyxia). 
A frequent cause of the asthenic form is injury to the brain 



84 DISEASES OF CHILDREN 

occurring at the time of delivery. Head injuries from pro- 
tracted labor or forceps delivery usually result in hemorrhage 
into the pia mater and as a consequence of such a lesion the 
respiratory centers fail to functionate. In the absence of hem- 
orrhage, malformations of the respiratory or circulatory organs, 
pulmonary atelectasis, pulmonary syphilis, and premature birth 
may be mentioned as causes. 

The reflexes are not abolished in the sthenic variety and the 
pulse is slow but perceptible. The vessels of the cord remain 
full and firm and the infant's muscle tone remains good. The 
symptoms disappear as soon as respiration is established. It 
presents a better prognosis than the asthenic variety, in which 
there is pallor of the body surface, abolition of reflexes, and 
imperceptible pulse. 

Treatment consists in promptly cleaning out the mouth and 
pharynx and stimulating the respiratory reflex by spanking, 
the alternate application of cold and warm water and resorting 
to artificial respiration if necessary. In the asthenic variety 
the warm bath alone should be employed, together with artificial 
respiration, but when the asphyxia is symptomatic of one of the 
serious conditions above enumerated, the prognosis is grave. 

CEPHALHEMATOMA. 

A cephalematoma is a tumefaction situated upon one of the 
cranial bones, usually over the parietal, caused by hemorrhage 
beneath the periosteum. It results from injury sustained during 
parturition, and is frequently encountered in children born 
through a narrow pelvis. Being entirely external no pressure 
symptoms result from such a hemorrhage. The swelling in- 
creases in size slightly during the first week and then slowly 
absorbs. The blood does not coagulate but bone cells are depos- 
ited in the periosteum over the swelling so that in cases that are 
several weeks old a parchment-like feel is imparted to the same. 
Surgical interference should not be resorted to unless infection 
occurs. 



DISEASES OF THE NEWBORN 85 

HEMATOMA OF THE STERNO-MASTOID MUSCLE. 

This usually affects the belly of the right sterno-mastoid 
muscle, most commonly occurring in breach labors, being the 
result of twisting of the head during parturition. A firm, 
elastic, egg-shaped swelling appears in the middle of the muscle 
about two weeks after birth and is accompanied by torticollis. 
It should disappear in the course of several weeks but sometimes 
the clot becomes organized and the torticollis persists for a long 
time, in which case it may require surgical treatment. 

INTRACRANIAL HEMORRHAGES. 

Apoplexy of the newborn occurs as a venous or capillary 
hemorrhage of the meninges of the brain, less frequently taking 
place in the cortex. It results from direct injury during birth. 
This condition is fully discussed under cerebral palsies. Other 
forms of injury to the nervous system encountered at this 
period are facial and brachial paralysis, resulting from pressure 
or traction upon the nerve trunks supplying these parts. 

SEPTIC AND OTHER INFECTIONS IN THE NEW-BORN. 

The newborn infant exhibits an apparent immunity to certain 
of the acute infectious diseases while toward others it shows the 
same susceptibility as an older infant. Iso doubt some of the 
immunity depends upon the presence of antibodies in the system 
derived directly from the mother through the placental circu- 
lation. Some of these antibodies may also be present in the 
mother's milk and for this reason a nursing infant is less 
susceptible to infections than a bottle-fed infant. 

The newborn is, however, highly susceptible to septic infection 
and the greatest care must be exercised to protect it from any 
possible septic source. The organisms mainly responsible for 
the septic manifestations encountered in the newborn are the 
streptococcus pyogenes and the staphylococcus pyogenes aureus. 

The general symptoms associated with sepsis are apathy and 



86 DISEASES OF CHILDREN 

weakness; feeble crj; fever; vomiting and diarrhea; distended 
abdomen ; rapid respirations and cyanosis ; at times convulsions. 
Jaundice frequently develops. The fever sets in toward the 
latter part of the first week or during the second week and does 
not yield to the usual therapeutic measures efficacious in gastro- 
intestinal disturbances. 

Local manifestations may be demonstrable such as a muco- 
purulent discharge from the nose; stomatitis; redness of the 
skin about the umbilicus; protrusion of the umbilicus and 
dilatation of the epigastric veins; bronchopneumonia and 
arthritis. 

Continued fever in the newborn should always be looked upon 
as a serious symptom. Rapid respirations and cyanosis with 
febrile manifestations and gastrointestinal disturbances are 
much more likely to signify pneumonia than pulmonary 
atelectasis. 

Inanition fever develops during the first three or four days 
after birth and disappears as soon as sufficient water and food 
are administered. 

Intestinal toxemia presents symptoms of fever and gastro- 
intestinal disturbances which, however, promptly clear up after 
a dose of castor oil (Morse). 

A high leucocyte count can usually be demonstrated to con- 
firm the diagnosis of sepsis. 

Other clinical types of infectious conditions encountered in 
the newborn are erysipelas, tetanus and gonorrheal infection 
of the eyes and joints. 

ERYSIPELAS. 

This is a form of cellulitis due to local infection with the 
streptococcus pyogenes. It most frequently originates at the 
site of the umbilical cord although an abrasion of the skin in 
any other part of the body may be the starting-point for the 
disease. The prognosis is usually grave, especially in cases 
resulting from infection of the umbilicus. 



DISEASES OF THE NEWBORN 87 

TETANUS. 

The bacillus of tetanus may be inoculated at the site of an 
abrasion of the skin or of a mucous membrane, or it may gain 
entrance through the umbilical stump. 

The symptoms are identical with those observed in the adult, 
the earliest manifestations being rigidity of the jaws, occurring, 
as a rule, shortly after the cord has dropped off. The trismus 
is followed by tonic spasms of the muscles of the neck and 
extremities, occurring paroxysmally. As a rule, it terminates 
fatally within a few days, although it may pursue a protracted 
course and result in recovery. Tetanus antitoxin should be 
administered as soon as the condition is suspected. 

GONORRHEA. 

Gonorrheal infection of the eyes is the most common form of 
infection with the gonococcus of Neisser encountered in infancy. 
Many cases of vulvitis in infants, however, are gonorrheal in 
nature. In recent years attention has also been called to the 
fact that arthritis in infants is frequently of gonorrheal origin. 
The arthritis is multiple in character and is a manifestation 
of a general septic infection with the gonococcus. Kimball 
reported eight cases of gonorrheal pyemia in infants in 1903 
coming under his charge at the Babies' Hospital in New York. 
They all terminated fatally. 

OPHTHALMIA NEONATORUM. 

The gonococcus of Neisser is responsible for the virulent type 
of conjunctivitis occurring in the newborn which at times results 
in destruction of the entire eye. When the infant is infected 
during parturition the symptoms make their appearance on the 
third or fourth day. In the cases where the symptoms are of 
later occurence infection probably took place after birth. 

The first signs of the infection are redness and swelling of 
the palpebral and ocular conjunctiva, puffiness of the eyelids 



88 DISEASES OF CHILDREN 

and catarrhal secretion. The secretion rapidly becomes puru- 
lent and the eye-lids infiltrated and leathery. In the virulent 
cases chemosis is pronounced and the cornea is deprived of its 
nutrition through compression of the blood vessels at the sclero- 
corneal margin. The cornea becomes opaque, its epithelium is 
shed and perforation may occur. 

A benign, non-gonorrheal type of ophthalmia is at times seen 
due to the ordinary pyogenic organisms. It is recognized by its 
mild course and the absence of the gonococcus in the secretion. 

The prognosis should always be guarded; it is especially 
unfavorable in cases which have not had the benefit of early 
treatment. The claim is made that from 25 to 30 per cent of 
all cases of blindness can be blamed on ophthalmia neonatorum. 

Treatment. — When the first symptoms of an ophthalmia are 
observed the eyes should be flushed hourly with a 2 per cent 
solution of boric acid and kept covered with compresses of an 
ice cold solution of the same. As soon as the discharge becomes 
thick and creamy, a few drops of a solution of nitrate of silver, 
three to four grains to the ounce should be instilled into each 
eye three times daily. If the discharge continues to increase 
it is better to discontinue the compresses and irrigate the eyes 
with several ounces of a warm boric acid solution every half 
hour. As the gonococci decrease in the pus the nitrate of silver 
should be used less frequently. As the inflammation subsides 
and the eye-lids lose their infiltrated character a few drops of 
a stronger solution of nitrate of silver (2 to 4 per cent) may be 
dropped upon the everted surface of the lids, care being taken 
not to permit the solution to get into the eye. This process 
should be followed by an irrigation with normal salt solution. 
In order to inspect the cornea satisfactorily from day to day and 
properly flush out the conjunctival sacs retractors must be made 
use of. 

When the cornea becomes involved a drop of one per cent 
solution of atropine should be instilled into the eye twice daily. 
In threatening perforation, esserine should be used. Aconite 



DISEASES OF THE FEWBOEN 89 

may be administered internally in the early stages and euphrasia 
in the later stages. The responsibility which these cases involve 
makes it advisable to always call an oculist in consultation. 

ACUTE FATTY DEGENERATION, OR BUHL'S DISEASE. 
This disease was first described by Buhl in 1860, and presents 
parenchymatous inflammation, fatty degeneration and hemor- 
rhages in the heart, liver and lungs. It is probably of infectious 
origin. It is rare, and is only seen in lying-in hospitals. The 
children are usually born asphyxiated, and they do not entirely 
recover from this state. Cyanosis supervenes, and they either 
die at this time, or the course of the disease is protracted, and 
bloody diarrhea, hemorrhage from the navel, mouth, nose and 
conjunctiva, and icterus, set in. Later, edema of the skin 
occurs, and death from collapse follows at about the end of the 
second week. The diagnosis can only be positively made by 
a microscopic examination of the organs. The course is 
always fatal. 

ACUTE HEMOGLOBINURIA, OR WINKEL'S DISEASE. 

In 1879 Winkel encountered a series of twenty-three cases 
of hemoglobinuria occurring in the new-born, associated with 
cyanosis, icterus, and hemorrhages in the various organs, with 
a fatal termination within thirty-two hours in the average of 
cases. The cause is unknown, but it is undoubtedly an infec- 
tion. Other cases have been reported, but not in such an 
extensive epidemic as the above. Hamill and Nicholson in a 
series of carefully studied infections in the new-born (" Archives 
of Pediatrics," Sept., 1903) found that a variety of micro- 
organisms is to be encountered, showing that careless nursing 
is responsible for these infections. 

MASTITIS. 
Inflammation of the mammae with abscess formation may 
result from attempts to squeeze the milk-like secretion from the 



90 DISEASES OF CHILDREN 

breasts which is normally present in a large percentage of 

infants. There is no reason for interfering with this secretion 

which eventually disappears of its own accord. Should an 

actual mastitis develop hot fomentations and belladonna should 

be prescribed. 

VAGINAL HEMORRHAGE. 

A bloody vaginal discharge appearing on the fifth or sixth 
day is occasionally observed in female infants. This usually 
subsides in two or three days and is of no pathological signifi- 
cance. Vaginal hemorrhage may, however, be a symptom of 
sepsis. In such cases the bleeding occurs later and is accom- 
panied by other manifestations of sepsis. 

ICTERUS NEONATORUM. 

Icterus, or jaundice, occurs as a symptom in Buhl's disease, 
WinkeFs disease, in septic infection and in cases of congenital 
malformation of the bile ducts. 

Physiological jaundice of the newborn occurs in about two 
thirds of all healthy infants, the percentage being somewhat 
higher in the premature and undersized. 

Endless theories concerning the etiology of icterus neonator- 
um have been advanced. According to Quincke, it results 
from resorption of bile from the intestine as a result of patency 
of the ductus venosus Arantii; according to Birch-Hirschfield 
it is due to a swelling of the capsule of Glisson following inter- 
ruption of the circulation in the umbilical vein. Hofmeier 
considers it of hematogenous origin depending upon an extensive 
destruction of red blood corpuscles. This process takes place in 
the liver shortly after birth. Czerny believes that it is due 
to infection. 

The most striking feature associated with a study of jaundice 
in the newborn is the strong disposition of the infant to develop 
this condition and the fact that its course is so benign and 
uneventful. Yon Reuss sums up the factors which all seem to 
contribute to this unusual disposition as follows: (a) Certain 



DISEASES OF THE KEWBOEK" 91 

mechanical factors, partly anatomic, partly depending upon the 
character of the bile itself at this age. (b) The abnormal 
amount of coloring matter found in the bile and the excessive 
production of bile pigments in the liver at this age. (c) The 
functional deficiency and vulnerability of the hepatic cells of 
the newborn. 

The discoloration of the skin is noticed on the second or 
third day, gradually increases in intensity for several days and 
then subsides. The jaundice usually clears up during the second 
week. In delicate and premature infants it may persist for 
several weeks. Jaundice which does not clear up in a week or 
two should be looked upon as pathological and not considered 
in the light of the "physiological" variety. 

The stools remain normal in appearance and bile continues 
to be secreted into the intestine. The urine is not discolored, 
the bile pigments not being excreted in the urine in solution but 
they can be demonstrated in the urinary sediment in an 
amorphous form. 

HEMORRHAGIC DISEASE OF THE NEWBORN. 

The newborn infant presents a predisposition to hemorrhage 
owing to the fact that the blood at this time of life fails to 
coagulate as readily as in the more mature infant. Slight 
injuries or abrasions are therefore likely to result in a consider- 
able loss of blood with serious consequences. Infections also 
increase this hemorrhagic tendency and so it is common to find 
a disposition to hemorrhage as one of the manifestations of 
sepsis and of syphilis in the newborn. 

The characteristic form of hemorrhagic disease of the new- 
born, however, known as melena neonatorum, occurs independ- 
ently of traumatism or of an infection, the bleeding taking 
place spontaneously from the mucous membranes or under the 
skin. The hemorrhage is usually extensive, is not influenced 
by the ordinary styptic measures and frequently terminates 
fatally. 



92 DISEASES OF CHILDREN 

As a rule no lesions are found to account for the bleeding 
although in a certain percentage of the cases small, round, 
superficial ulcers can be demonstrated in the stomach and 
duodenum. 

The infant in usually a healthy, well-nourished babe at birth 
and shows nothing abnormal. Several days after birth blood 
will be discovered in the stool or the infant vomits bloody 
gastric contents and a rapidly developing anemia results. If 
an infant vomits a dark or brownish substance or if the stool 
contains particles resembling meconium after the third day a 
test for occult blood should at once be made. The early resort 
to the subcutaneous or intramuscular injection of human blood 
serum, from twenty to thirty cubic centimeters, taken from one 
of the parents, offers the best chances for arresting the condition. 
When the loss of blood has been large the introduction of a larger 
amount of citrated blood, through the anterior fontanel, will 
be necessary. 

SUDDEN DEATH IN INFANTS. 

Sudden death in the newborn is most frequently due to 
cerebral hemorrhage resulting from compression of the head 
during birth or from hemorrhage into the internal organs. The 
latter occurs most frequently in breach cases and in precipitate 
labors of large infants. 

Malformations of the viscera are a common cause of sudden 
death in young infants. Enlargement of the thymus gland may 
be a cause of sudden death. While Faltauf denies that pressure 
from the thymus plays a role in the death of these infants, 
attributing it to the clinical entity which he has termed status 
lymphaticus, or lymphatism, still the theory that thymic death 
can occur has many adherents, notably in Jacobi. The latter 
writes : "It ( the thymus gland) is largest, normally, from the 
third to the twentieth month; about the ninth month it was 
found, in usual instances, from 1.5 to 2 centimeters in thickness. 
As the distance between the manubrium sterni and the vertebral 
column is but two centimeters about the eighth month of life 



DISEASES OF THE NEWBORN 93 

the slightest increase of an enlarged thymus through distended 
circulation, by crying or otherwise, may prove fatal ; for besides 
the thymus, the esophagus, the trachea, the blood vessels, and 
the sympathetic and pneumogastric nerves are located in that 
narrow space. Bending the head backward during tracheotomy 
proved fatal. Swelling of the thymus in a cold bath may be dan- 
gerous" (Therapeutics of Infancy and Childhood) . In discuss- 
ing a case recently reported by Caille, Jacobi called attention to 
the fact that but a few are on record since Kopp reported his first 
case of thymic asthma nearly a hundred years ago. He related 
a case operated upon by Konig in which the gland was partly 
excised with life-saving results. For detailed report on this 
subject the reader is referred to Jacobi's monograph (Trans. 
Ass. of American Thys., Vol. III). 

Atelectasis. — This is either congenital or acquired. Complete 
atelectasis is seen in asphyxia neonatorum. In feeble infants 
atelectasis may develop after the lungs have been functionating, 
and if progressive it results in death. It is due to an inability 
of the infant to adjust itself to its new environment. As long as 
it received its sustenance and its oxygen from the maternal 
blood supply it developed normally but when cut loose from 
this parasitic life it succumbs. Areas of atelectasis develop 
in the lungs during an attack of bronchitis or bronchopneumonia 
and may be of sufficient extent to seriously interfere with 
respiration. In many cases of congenital debility and maras- 
mus the only lesion found post-mortem is pulmonary atelectasis. 

Asphyxia from the aspiration of liquids into the larynx is 
at times a cause of sudden death in feeble infants. Sudden 
death may arise from laryngismus stridulus or during general 
convulsions. Sudden death with hyperpyrexia may occur in 
almost any of the acute infectious diseases. 



CHAPTER VI. 

DISEASES OP THE MOUTH. 

DENTITION. 

The teeth which are erupted during infancy are spoken of 
as the temporary or milk teeth. They are twenty in number 
and are gradually replaced by the permanent teeth which 
number thirty-two. At the time of birth the teeth are present 
in the alveolar process of the jaw, in an immature form, 
enclosed in the so-called dental sacs. When the infant is being 
properly nourished and its mineral salt metabolism is normal the 
development of the teeth from these tooth germs progresses hand 
in hand with the development of the jaw and the osseous system. 
The eruption of the teeth begins at about the sixth month and 
is completed at the end of the second year. Any condition, 
however, interfering with the child's nutrition or any constitu- 
tional disease which disturbs the calcium metabolism exerts 
a marked influence upon the development and eruption of the 
teeth. The result of such pathological conditions is delayed 
dentition and the eruption of imperfectly developed, perishable 
teeth. The usual order of the eruption of the teeth is as follows : 

Six to eight months after birth the two lower central incisors 
should make their appearance; the upper central incisors usually 
appear a month later. The upper lateral incisors are the next 
in order, and at the end of a year the upper anterior molars 
begin to erupt. At the fourteenth month the lower lateral 
incisors erupt, followed by the lower anterior molars. 

The canine teeth appear between the sixteenth and twentieth 
months, and at the end of the second year the posterior molars 
are added to complete the set. 

Ordinarily it may be stated that at one year of age there 
should be six teeth; at one and one-half years of age twelve 



DISEASES OF THE MOUTH 95 

teeth ; at two years, sixteen teeth and at two and one-half years, 
twenty teeth. 

Soon after the eruption of the milk teeth absorption begins, 
commencing at the apex of the root and extending to the crown, 
so that they are either lost by an accidental tearing of the 
membranous attachment to the gums, or are displaced by the 
advancing permanent teeth. 

The eruption of the permanent teeth begins at the 6th year, 
the first to come being the molars, or the "six-year molars." 
These are followed by the incisors, (7 to 8 years). Next to 
appear are the bicuspids, (9 to 10 years) ; then the canines at 
12 years; the second molars at 12 to 15 years and finally the 
third molars or "wisdom-teeth" at 17 to 21 years. 

Dentition is a purely physiological process, and should there- 
fore run a normal, uneventful course. This is, however, 
unfortunately not always the case and there is no doubt that 
many infants are unnaturally peevish and uncomfortable and 
present digestion derangements when they are teething. Much 
harm, however, has been done by attributing many disorders to 
teething which should have been thoroughly investigated and the 
true cause found and remedied. 

As a rule lancing the gums is unnecessary and is to be 
condemned as a routine practice, but when the gums are tense 
and irritated and the tooth is ready to come through relief 
will frequently follow this procedure. 

The proper care of the teeth is a hygienic essential as carious 
teeth are a serious menace to the child's health. A focal 
infection in the mouth may spread to the tonsils and the 
lymphatic glands under the jaw and may also induce serious 
constitutional disturbances. It is also important that the milk 
teeth be preserved as long as possible, for their premature loss 
interferes with the growth and development of the jaw, thereby 
inviting a contracted palate, abnormally small jaw or irregu- 
larities in the permanent teeth. 

The following remedies are indicated in the disturbances 
encountered in the teething infant: 



96 DISEASES OF CHILDREN 

Bell, and Cham, are perhaps the most frequently employed 
teething remedies, Chamomilla being indicated by irritable 
temper ; greenish, offensive diarrhea, and circumscribed redness 
of the cheeks. Belladonna is indicated when there is fever; 
flushed face; redness and swelling of the gums; vomiting. 

Ferrum phos. is especially useful in anemic infants; cough 
during teething. 

Calcarea phos. is indicated in the delayed teething of rickets 

and malnutrition. The teeth are imperfectly formed and 

decay early. 

ABNORMALITIES OP THE TEETH. 

The most characteristic deformity seen iu the teeth is the 
condition first described by Hutchinson, which occurs in con- 
genital syphilis and is known as "Hutchinson's teeth." The 
enamel is deficient upon the cutting surface of the upper central 
incisors and as a result of this defect a semilunar notch is 
worn into the edge of these teeth. Furthermore, they are 
shorter than normal and their sides somewhat sloping, giving 
them the form of a screwdriver, being narrower at their cutting 
edge than at the root. The canine teeth are also rudimentary 
and pegshaped. 

The milk teeth are not characteristically affected by syphilis ; 
they may be poor in quality and decay early, or they may show 
irregularities in form and in their enamel covering. Any form 
of stomatitis, however, can affect the development of the teeth. 

Riclcets delays the eruption of the teeth, and in rachitic 

children they are, as a rule, abnormally soft and decay early. 

The permanent teeth may show transverse ridges or a serrated 

edge as a result of an acute illness occurring during the teething 

period. Any disease affecting the general nutrition naturally 

shows its influence upon the teeth if it be active at the time 

of their eruption. 

STOMATITIS. 

The term stomatitis is applied to the several forms of inflam- 
matory affections involving the mucous membrane of the buccal 



DISEASES OF THE MOUTH 97 

cavity. It is a common affection among children, and may be 
either of mechanical, constitutional, bacterial or myotic origin. 

CATARRHAL STOMATITIS. 

This form of stomatitis presents an acute diffuse inflamma- 
tion of the mucous membrane of the mouth. 

Etiology. — The exciting cause may be mechanical irritation 
from a nipple or comforter, or from too vigorous cleansing of 
the baby's mouth. It may also result from giving the food too 
hot or from bacterial infection. In the majority of instances, 
however, catarrhal stomatitis is simply a symptom of some 
general acute infectious disease or of a gastrointestinal 
derangement. 

Symptoms. — Primarily there is heat and dryness of the 
mucous membrane of the mouth and gums, together with 
redness and swelling, which is generally uniform, although it 
may be more marked in circumscribed areas. This is followed 
by increased secretion of mucus and saliva, which generally 
dribbles from the mouth. Pain is present, and the pathogno- 
monic symptom, "The child seizes the nipple eagerly, but after 
a few seconds drops it with a cry," is explained by this exquisite 
tenderness of the mouth. The child is fretful and feverish, 
and, owing to the inability to nurse successfully, soon loses in 
weight. It is usually of short duration and does not terminate 
in ulceration. 

PITYRIASIS LINGILE, 

Is a chronic catarrhal inflammation involving the upper sur- 
face of the tongue, resulting in the characteristic condition known 
as lingua geographica. It begins as a circular patch or patches 
of epithelial hyperplasia forming elevated whitish spots, which 
enlarge and ultimately desquamate in the center, resulting iu 
irregular plaques, with islands of normal mucous membrane 
interspersed between the hyperplastic epithelium. Several of 
the ring-like lesions coalesce and form the geographical pattern 
giving the disease its name. This affection shows great ten- 



98 DISEASES OF CHILDREN 

dency to recur, the interval between the disappearance of the 

old lesions and the reappearance of a new annular patch being 

usually of short duration. It is met with in children of all ages, 

in the healthy as well as sickly, although perhaps most frequently 

in the rachitic. 

APHTHOUS STOMATITIS. 

Aphthous stomatitis is characterized by the appearance of 
small, round, circumscribed, yellowish plaques upon the mucous 
membrane of the mouth and tongue. 

Etiology. — The etiology of this affection is unknown. 
Forchheimer considered aphthous stomatitis an acute infection 
of intestinal origin and he compared it to the foot and mouth 
disease of cattle. Filatow believed it to be a local infection, as 
it often attacks several children in one family simultaneously. 
It is most commonly seen from the first to the third year. 

Symptoms. — The lesions appear mainly upon the mucous 
membrane of the anterior portion of the mouth and tongue; 
they are seldom found upon the tonsils or base of the tongue. 
They consist of small, round, dirty-white or yellowish plaques, 
slightly elevated and surrounded by a red areola. There is 
accompanying pain, salivation, offensive breath, inability to eat, 
slight fever. The duration is from one to two weeks. 

BEDNAR'S APHTHiE. 

This condition is only seen in infants from one to six weeks 

old; it is characterized by the formation of round, superficial 

ulcers situated at the bases of the palate. The prognosis is 

usually favorable although deep ulceration of the tissues has 

been observed. It is no doubt brought on by traumatism 

from the nipple. 

APHTHAE EPIZOOTICS. 

This is an infectious form of vesicular stomatitis, resulting 
from infection with the milk from cows affected with the disease. 
There is more fever than in aphthous stomatitis, salivation and 
and coryza are accompanying symptoms, and the vesicles do 



DISEASES OF THE MOUTH 99 

not appear on the dorsum of the tongue but are usually situated 
on the soft palate, lips, gums and cheeks. There is also fetid 
breath, sometimes vomiting and diarrhea. It runs its course in 
from one to two weeks. 

In varicella vesicles often appear in the mouth, but the 
cutaneous manifestations are sufficient to differentiate it from 
aphthous stomatitis. 

ULCERATIVE STOMATITIS; PUTRID SORE MOUTH. 

This variety presents an inflammation of the mucous mem- 
brane of the mouth, accompanied by ulceration. 

Etiology. — The destructive inflammation of ulcerative stom- 
atitis is due to a local infection. Although it has occurred 
epidemically, no specific micro-organism has been demonstrated. 
Smears taken from the lesions show a fusiform bacillus accom- 
panied by a spirillum, identical with the bacteriological findings 
in Vincent's angina. It is only seen in cihldren who have teeth 
and is often associated with carious teeth. 

Pathology. — The process begins with an inflammation of the 
anterior border of the gums, at the roots of the teeth, most 
frequently on the lower jaw. Redness and swelling are the 
initial changes, after which a yellow line, indicating the begin- 
ning of the necrotic process, develops along the alveolar border 
and extends downwards. From the gums the process extends 
to the inner margin of the lips, and large ulcers are generally 
formed on the lining of the cheeks opposite to the molar teeth. 
The sides of the tongue frequently participate, becoming in- 
fected by direct contact with the lesions. 

Symptoms. — In the beginning of the disease there are the 
usual symptoms of stomatitis, but soon the characteristic foul 
breath develops, the pain becomes intense, and prostration and 
fever is more marked than in the other forms. This is easily 
understood when we consider the severity of the process and the 
intoxication resulting from the absorption of the putrid material 
forming in the mouth. The course is more protracted than 



100 DISEASES OF CHILDREN 

in the other forms of stomatitis and the child's general condition 
must be improved as well as looking after the local condition. 

PARASITIC STOMATITIS; THRUSH. 

Parasitic stomatitis is an infection of the mouth due to the 
development of a parasitic fungus within the mucous membrane. 
It is characterized by the appearance of milk-white patches 
which are difficult to remove and have a tendency to coalesce 
and spread extensively. 

Etiology. — The saccharomyces albicans, a fungus of the 
group saccharomyces, is found in the mucous membrane where- 
ever the lesions develop. If a portion of the white pellicle be 
removed and placed on a slide with a drop of liquor potassse 
the mycelium and the spores can be demonstrated. 

Artificial feeding, early life, exhausting diseases, catarrhal 
stomatitis, insufficient salivary secretion, unsanitary surround- 
ings and lack of proper care of the nipples and of the baby's 
mouth are the etiological factors. The disease can be communi- 
cated directly from one patient to another, and is quite common 
in foundling asylums and among the poorer classes. 

Pathology. — The spores of the saccharomyces albicans, find- 
ing their way into the mouth of the infant, soon develop their 
mycelia, which penetrate the layers of the mucous membrane 
and form the white patches or elevations so characteristic of the 
affection. These patches are difficult to remove, as they are 
within the mucous membrane, but there is no exudation or pus 
formation accompanying the {process. The lesions usually 
begin as small, white points on the inner surface of the cheeks, 
quickly spread and coalesce, so that in a short time the entire 
buccal cavity and pharynx may be involved. Extension to the 
esophagus is rare, and to the stomach still rarer, as it confines 
itself almost exclusively to the squamous epithelium. Eare 
cases, however, are on record in which these localities were 
affected, beside the lower rectum the female genitalia, the upper 
respiratory tract, intestines, and abraded cutaneous surfaces. 



DISEASES OF THE MOUTH 101 

Preceding the outbreak of thrush the mucous membrane of 
the mouth is hot and dry ; later there is a sticky mucous secre- 
tion, acid in reaction. This is partly due to a lack of the 
normal alkaline salivary secretion, and to saccharine fermen- 
tation, the result of the growth of the fungus. 

Symptoms. — Beside the objective symptoms already de- 
scribed there is generally pain due to the catarrhal stomatitis set 
up by the fungus. The prognosis depends upon the infant's 
condition and as a rule is favorable. In poorly nourished, 
sickly infants it may be difficult to eradicate. 

The white pellicle of thrush closely resembles flakes of co- 
agulated milk and in the beginning is often mistaken for such ; 
but the difficulty with which these spots are removed and the 
associated stomatitis readily differentiates it from such a con- 
dition. Thrush has been mistaken for diphtheritic deposit, but 
here the age of the patient, together with the associated con- 
ditions, the absence of foul breath, glandular involvement, fever 
and prostration, and the superficial character of the lesions, 
should readily differentiate the two. 

GANGRENOUS STOMATITIS— NOMA. 

A destructive inflammatory process involving usually the 
cheeks and developing secondarily to one of the exanthemata or 
to some exhausting disease. 

Etiology. — It generally follows upon measles, scarlet fever, 
typhoid fever, or some form of exhausting disease, occurring most 
frequently between the age of three and six years and in the 
poorer classes. The pyogenic bacteria, notably the streptococcus 
pyogenes, are responsible for the destructive pathological 
changes. In a certain number of cases the diphtheria bacillus 
has been present (Walsh). 

Pathology. — Beginning on the inside of the cheek or near 
the corner of the mouth, a small vesicle, filled with a turbid fluid, 
is formed. The vesicle breaks and leaves a superficial ulcer 
with a hard, infiltrated base, which can be felt through the 



102 DISEASES OF CHILDREN 

cheek. This breaks down and a rapidly spreading gangrenous 
process develops, with no tendency to limitation. The affected 
parts become infiltrated and edematous, presenting a shiny, 
livid appearance. 

Symptoms. — Often the first symptom noticed will be the 
ulcer, as the vesicle is easily overlooked. The breath is foul, 
prostration profound, and the temperature of the septic fever 
type. The prognosis is unfavorable, the patient either suc- 
cumbing to septicemia or to a secondary bronchopneumonia; 
fatal hemorrhage is rare. In the case of recovery there is 
usually marked deformity. 

Treatment of Stomatitis. — All forms of stomatitis can be 
prevented to a great extent by strict attention to the hygiene of 
the mouth, as well as by careful supervision of the diet and 
general hygiene of the child. With artificially-fed babies, it 
is important to have nipples and bottles kept perfectly clean 
and sterile. During the course of an acute illness, especially 
one of the infectious fevers, it is imperative to keep the mouth 
in a clean condition, for it is in these cases that noma may 
develop, particularly in the enfeebled and poorly nourished. 

Should stomatitis develop, a mild antiseptic wash will be 
sufficient to carry the case through, excepting in the gangrenous 
form, which is, strictly speaking, a surgical disease. For this 
purpose, either a 2 per cent Boric acid solution, alcohol diluted 
with three parts water, or, a solution of potassium chlorate, one 
per cent, may be employed. The latter is especially useful in 
the ulcerative form. In stubborn cases of thrush it may become 
necessary to touch the patches carefully with a 2 per cent 
solution of Silver nitrate; this is to be followed by rinsing the 
mouth with salt water. 

The diet is important in ulcerative stomatitis. By a restric- 
tion in the use of all salty articles of food, and the free use of 
fruit juices and vegetable broths, these cases recover more 
promptly than under ordinary treatment. Owing to the pain- 
ful condition of the mouth the diet should be restricted to liquids 



DISEASES OF THE MOUTH 103 

and semi-solids, and in older children the use of a tube or 
feeding-cup with a spout will be very grateful. 

Borax is perhaps the most useful remedy in the aphthous and 
parasitic form, especially in the early stages, with heat and 
dryness of the mouth. It may be applied directly to the 
affected parts either in pure form or in the first decimal tritur- 
ation, which, being slightly sweet, is more pleasant to the child, 
or it may be used in the form of a saturated solution. 

Mercurius may be indicated in all forms, but pathologically 
it corresponds most closely to the ulcerative form. 

Ars. — Thrush; exhausting diseases; prostration; dryness 
of mouth. 

Baptisia. — Ulcerative stomatitis; great fetor of breath; 
offensive diarrhea; typhoid state. 

Bry. — Catarrhal stomatitis; great dryness of mouth. 

Hydrastis. — Superficial ulceration; tenacious mucus. 

Natr. mur. — Gums spongy; superficial ulcers on tongue 
and cheeks. 

Nitr. ac. — Ulcerative stomatitis; after mercury; fetid breath 
and acrid saliva; acrid diarrhea; cracking of the corners of 
the mouth. 

Rhus tox. — Great restlessness; saliva bloody; lips cracked. 



CHAPTER VII. 

DISEASES OP THE GASTROINTESTINAL TRACT. 

The chief etiological factor in diseases of the stomach in 
infants is improper feeding. This may mean any of the follow- 
ing errors: (a) the use of foods of improper composition; (b) 
the administration of abnormally large quantities of food; 
(c) irregularity in the time of feeding, and (d) improper 
temperature of the food. Beside these factors, infection also 
plays an important part as a cause of gastric disturbances. 
Bacteria or their toxins may act either directly npon the mucous 
membrane of the stomach or toxins circulating in the blood 
during the course of an infectious disease may induce serious 
gastric symptoms. 

An important fact to bear in mind is the impossibility of 
drawing a sharp line of demarcation between diseases of the 
stomach and intestines. In adults there is greater possibility 
of doing this. The infantile stomach, however, is only a 
dilation of the alimentary canal and is not completely differen- 
tiated from the same. Its position, at first, is almost verticle; 
its capacity is relatively small and its sphincters are immature. 
Physiologically it is immature, the main work of digestion 
falling upon the intestinal tract. Under normal conditions, 
therefore, the food (breast-milk) is coagulated shortly after 
reaching the stomach by the rennin of the gastric juice. 
Hydrochloric acid is now secreted and the casein is converted 
into acid albumin (syntonin). The action of the pepsin 
simultaneously secreted is feeble. In fact, the food does not 
remain long enough in the stomach to be digested completely, 
the bulk of the digestive process taking place in the small 
intestine. Vomiting occurs readily and therefore any food that 
is unsuitable can readily be disposed of and the stomach not 



DISEASES OF THE GASTROINTESTINAL TRACT 105 

harmed thereby. Should it pass into the intestine, colic and 
diarrhea usually result. 

Vomiting. — Persistent vomiting from birth indicates either 
cardiac or pyloric obstruction. In the former deglutition sounds 
are absent, while in the latter the food is generally retained 
abnormally long before being rejected. At the same time 
dilatation of the stomach develops together with other signs of 
pyloric obstruction. 

The natural tendency for infants to vomit must not be lost 
sight of. The cardiac sphincter is poorly developed and owing 
to the habit of gulping the food too rapidly or overfilling the 
stomach, vomiting is a common symptom. When the milk is too 
rich in fat it regurgitates shortly after nursing without being 
curdled. In indigestion the food is usually vomited an hour 
or more after nursing and it is curdled aud sour. In acute 
gastritis there is fever; the food is promptly rejected and 
mucus is present in the vomitus. In pyloric obstruction vomit- 
ing takes place after the stomach has become overfilled and it is 
projectile in character. The vomiting of intestinal obstruction 
is forceful and persistent; at first, gastric contents are rejected 
and later fecal matter appears. The vomiting of brain disease 
(reflex vomiting) is projectile and unassociated with any gastric 
derangement. Cyclic vomiting is periodic ; it occurs in older 
children and is associated with symptoms of acidosis. 

For purposes of chemical examination the gastric contents 
may be recovered by means of a catheter. Residual food will 
be found in cases of dilatation of the stomach and in pyloric 
stenosis. Free hydrochloric is normally present in the gastric 
contents but cannot be demonstrated after a feeding of milk 
because the milk combines with the hydrochloric acid forming 
an acid albuminate. The tests for occult blood should be made 
when the vomitus presents the characteristic appearance of 
coffee-grounds. In serious nutritional disturbances free hydro- 
chloric acid may be absent. 



106 DISEASES OF CHILDREN 

ACUTE GASTRIC INDIGESTION; DYSPEPSIA. 

An attack of indigestion in an infant or in a young child 
may be accompanied by a train of general symptoms which are 
at times of an alarming character. As a rule there is only noted 
the general discomfort, nausea and vomiting caused by the 
presence of undigested food in the stomach. In the more serious 
cases, however, fever, drowsiness, fetid breath and headache are 
also observed due to the toxemia associated with the condition. 
Acetone and diacetic acid may be found in the urine as well 
as a trace of albumin. In children of a certain type convulsions 
are apt to set in, or severe uncontrollable vomiting may occur. 
Ordinarily, emptying of the stomach and intestinal tract gives 
speedy relief of the symptoms but in some cases the toxic 
manifestations persist for some time after this has taken place. 

Etiology. — Indigestion is a frequent disturbance in young 
infants that are artificially fed. The digestive powers of the 
stomach are feeble and it is not very tolerant to any food 
excepting woman's milk. If food be taken in larger quantity or 
in more concentrated form than the stomach can manage, it 
will not be digested; irregularity in feeding, especially too 
frequent feeding, is also a prolific cause of indigestion. If the 
milk is not fresh it may produce serious toxic symptoms. 

In older children the same exciting causes which are active 
in adults are frequently found. Irregularity in eating is a 
common cause of indigestion in children, and since they are apt 
to overeat, they frequently suffer from attacks of indigestion. 
Improper mastication of the food, usually due to bad teeth or 
malocclusion must always be considered as a possible cause. 
Lack of proper attention to the bowels and indulgence in the 
articles of diet which are especially forbidden to children, such 
as nuts, fruit-cake, cheese, pastry and cheap candy is also 
frequently noted as an etiological factor. Some children have a 
subnormal tolerance for sugar and fats and they are conse- 
quently readily upset by candy and ice cream even when these 



DISEASES OF THE GASTROINTESTINAL TRACT 107 

are of good quality. Raw fruits must also be given to children 
with caution and when fruit is permitted it is most essential 
that it be clean and neither under- nor over-ripe. 

Symptoms. — In infants the first symptoms that will attract 
attention are restlessness, crying and vomiting. The vomited 
matter consists of curds, undigested or partially digested food, 
as the case may be, and it is usually sour and mixed with mucus. 
The acidity is mainly due to the presence of an excess of lactic 
acid. 

Should the stomach not empty itself completely, severe cons- 
titutional symptoms may occur from the absorption of products 
of incomplete digestion. The infant develops a high fever, 
becomes apathetic and prostrated; the tongue is coated, the 
epigastrium bloated, and diarrhea supervenes. This condition 
may be associated with general convulsion. 

Older children are usually feverish, complain of headache, 
nausea, and gastric pain; the advent of vomiting brings relief. 
The vomitus may contain food that has been in the stomach 
many hours. 

A mild attack of indigestion may subside spontaneously after 
the stomach has been emptied either by vomiting or fasting; 
in the more severe attacks troublesome vomiting and toxemia or 
an acidosis may be associated. The child's digestion may be 
impaired for a long time after such an attack. A proper regime 
of diet and general treatment is necessary in such cases to 
prevent recurrences or a protracted digestive disturbance. 

Treatment. — The management of dyspepsia in the artifi- 
cially fed infant is discussed in the chapter on "Infant Feeding." 
In the more serious cases lavage of the stomach should be 
resorted to. 

In older children lavage is not readily employed and we 
should encourage vomiting by giving copious draughts of luke- 
warm water to which some bicarbonate of soda has been added. 
If the symptoms are serious and the child cannot vomit an 
emetic should be used. The bowels should also be promptly 



108 DISEASES OF CHILDREN 

moved by means of a low enema of soap and water followed by a 
high irrigation with normal salt solution if fever and toxemia 
are present. 

Remedies are seldom necessary in infants after the stomach 
has been emptied and the diet carefully regulated. Infants with 
habitual indigestion, however, will require a remedy such as 
ipecac, nux vomica or pulsatilla. The same holds good for older 
children. One of the following remedies will be found useful 
during the attack. In older children, who can relate their 
symptoms, we are often capable of averting an attack by an 
early prescription. 

Abies nigra. — Sensation of a hard-boiled egg in the stomach. 

Antimon. crud. — Tongue white, heavily coated ; great nausea ; 
results of overeating. 

Arsenicum. — Indigestion after chilling the stomach. There 
is severe gastralgia; nausea and vomiting; craving for water 
which is taken in small sips at frequent intervals ; prostration ; 
albuminuria. 

Bell. — Throbbing headache; strawberry tongue; convulsions. 
It is the best remedy for the febrile case with toxemia. 

Bry. — During summer and sultry weather; anorexia, thirst 
for large amounts of water; mouth dry; distress and pain in 
stomach, as of a load. 

Ipecac. — This is the most important remedy for persistent 
nausea and vomiting. 

Nux vomica, — This is the best remedy for the ordinary 
case of indigestion brought on from overeating. There is a bad 
taste; the tongue is coated; breath offensive; nausea, with 
ineffectual effort® to vomit ; belching ; gastric distress ; headache 
and constipation. 

Pulsatilla is indicated in subacute cases of indigestion in 
children suffering with post-nasal catarrh; coated tongue; 
delicate digestion easily upset by any rich food. Mild, nervous 
type of children. 



DISEASES OF THE GASTROINTESTINAL TRACT 109 

CHRONIC INDIGESTION. 

The term chronic indigestion is applied to a group of cases 
in which a disturbance of the digestive function with resulting 
malnutrition are the leading clinical features. In some in- 
stances gastric symptoms predominate while in others the intes- 
tinal tract is chiefly affected. In the majority of instances it 
is, however, impossible to draw a sharp line of distinction 
between the symptoms which result from a deranged gastric 
function and those due to the associated intestinal disturbance. 
It is well to bear in mind that we are usually dealing with a 
child whose entire alimentary tract is in a subnormal condition 
and that under such circumstances there is no practical value 
in attempting to differentiate between a gastric indigestion 
and an intestinal indigestion. 

The results of chronic indigestion are far reaching upon the 
child's general health. Primarily, malnutrition and anemia 
develop from a failure of the proper digestion and assimilation 
of the food. The child becomes irritable and peevish and may 
develop serious nervous symptoms. The latter are either due to 
the malnutrition or they may be toxic in character from an 
intestinal toxemia. 

The dyspeptic symptoms which are commonly observed in 
these cases are loss of appetite or a perversion of the same; 
distress after eating and other gastric symptoms such as belch- 
ing, nausea, vomiting, heartburn and pylorospasm; intestinal 
flatulency and abdominal pains; diarrhea or constipation. 

Etiology. — Chronic indigestion may result from long- 
continued dietetic errors especially when these date back to 
infancy. Overfeeding or the use of a food not suited to the 
child's age, such as fat or starchy foods in excess may result in 
serious digestive disturbancs difficult to eradicate. In older 
children an improper diet is frequently found responsible for 
the indigestion or we may find that the child is drinking 
excessive quantities of milk, especially with its meals, or eating 



110 DISEASES OF CHILDREN" 

between meals, and thus overtaxing its digestion. There may 
be a subnormal tolerance for certain food elements, notably for 
fat and sugar. Such children are likely to develop attacks of 
recurring vomiting or fever of intestinal origin when they over- 
step the tolerance for these foods. There is a growing tendency 
to look upon some of the chronic digestive disorders, especially 
those of intestinal origin as forms of deficiency diseases 
(McCarrison, Studies in Deficiency Diseases, 1921), 

Constitutional causes are frequently operative. A neuro- 
pathic or a gouty heredity ; a frail constitution with the " Stiller 
type" of build, namely a long, narrow chest with acute costal 
angle, marked mobility of the tenth rib and predisposition 
to enteroptosis, are strong predisposing causes. 

Chronic infections like tuberculosis and focal infections in 
the tonsils and teeth may be etiological factors. Some cases 
date back to an acute infection of the gastrointestinal tract 
from which the child has never fully recovered but which marks 
the beginning of the present trouble. Carious teeth and maloc- 
clusion should always be looked for in chronic indigestion. 

Mechanical factors are atony of the stomach; dilatation and 
ptosis of the stomach; ptosis of the colon; dilatation of the 
colon; long, angulated sigmoid. 

Dilatation of the stomach may result from dietetic errors in 
infancy or from pyloric obstruction during infancy or it may 
develop as a symptom of rickets. In older children it can 
develop from overloading the stomach, especially if there is 
gastric atony. Ptosis also may lead to dilatation by causing a 
delay in the emptying time of the stomach. An atonic stomach 
readily dilates if kept continuously overfilled and serious toxic 
symptoms may occur in conjunction with food retention in 
such a stomach. 

Intestinal stasis from a ptosed or dilated colon or an elongated 
sigmoid may result in the development of an intestinal toxemia. 
The symptoms referable to intestinal toxemia are varied, 
prominently among which may be mentioned nervous irritabil- 



DISEASES OF THE GASTROINTESTINAL TRACT 111 

ity; headache; disordered sleep; enuresia; recurring fever; 
chronic skin eruptions. Kerley (Amer. Jour. Diseases of 
Children, April, 1920) reports a series of interesting roentgen- 
ray studies in children with gastrointestinal disorders and 
points out the importance of making use of roentgenograms in 
the diagnosis of these affections. The abnormalities which were 
demonstrated were pylorospasm; dilatation and ptosis of the 
stomach; dilatation of the colon; ptosis of the colon and elon- 
gated and angulated sigmoid. 

Symptoms. — The symptoms will depend largely upon the 
type of case, that is, whether the trouble is chiefly dietetic or 
whether we are dealing with a condition which is mainly 
mechanical in nature. Cases in which gastric symptoms pre- 
dominate will show decided disturbances in the appetite and if 
there is atony, gastric splashing can be demonstrated in the 
stomach region. As a rule there is distress in the epigastrium 
after eating and tenderness to pressure in this region. When 
there is ptosis with delayed emptying and retention of food 
recurring attacks of vomiting frequently occur. In the intestinal 
form there is diarrhea; peristaltic unrest; abdominal pains; 
mucus in the stools together with undigested fat and vegetable 
detritus and usually abdominal distention. 

Fat indigestion is the predominating feature in some cases. 
These are characterized by the presence of abnormal amounts 
of fat and fatty acids in the feces, the stools being loose and 
acid in reaction. The underlying cause is usually a pancreatic 
insufficiency. 

In carbohydrate indigestion the stools are liquid, of a gruel- 
like consistency and yellow color, they are frothy, due to 
fermentation and their reaction is acid. There is little or no 
mucus. Undigested starch granules can be demonstrated by 
microscopic examination. There is usually much gas in the 
intestines and the abdomen is distended. The severe type of 
intestinal indigestion in which there is both fat and carbo- 
hydrate indigestion with associated malnutrition and prominent 



112 DISEASES OF CHILDREN 

abdomen is clinically best known under the name of coeliac 
disease. 

MUCOUS colitis is usually associated with protein indiges- 
tion; at least these cases are benefited by a diet from which 
proteins are excluded and which consists chiefly of green 
vegetables and cereals. In mucous colitis there is a tendency to 
constipation; the stools are large and formed and are usually 
coated with tenacious mucus. At times mucous casts of the 
intestine are passed with colicky pains. Nervous symptoms 
and malnutrition are associated. 

Infantilism. — There is a type of malnutrition with stunted 
growth due to chronic intestinal indigestion, which was first 
described by Herter and named by him Intestinal Infantilism. 
Children presenting this condition are stunted in growth; the 
abdomen is large; the stools are abnormally large, containing 
an excess of fat and fatty acids and the bacterial flora is 
predominatingly Gram-positive. A marked indicanuria is 
also observed. 

Diagnosis. — The diagnosis of chronic indigestion particu- 
larly of the intestinal type, can usually be made from the 
appearance of the child alone. The malnutrition, anemia, 
stunted growth in cases of long standing and the prominent 
abdomen are quite characteristic. The condition of the bowels 
is also of diagnostic value. Diarrhea is usually present in the 
earlier stages; the stools being large and containing, beside 
undigested food particles, an abundance of mucus. They are 
abnormally offensive and when fermentation is a prominent 
feature they are acid in reaction and are expelled with a great 
deal of gas. Undigested fat is present in large amounts as well 
as some unaltered starch when this has entered largely into the 
diet. In the later stages the stools are apt to become consti- 
pated, usually being pale in color and abnormally large. The 
stool is often coated with mucus. 

In young children the differential diagnosis between chronic 
intestinal indigestion and tubercular peritonitis must be made. 



DISEASES OF THE GASTROINTESTINAL TRACT 113 

The latter is excluded by the absence of a continuous fever, the 
abdominal tympany without evidence of fluid or enlarged 
mesenteric glands and the negative von Pirquet reaction. 

Hirschsprung's disease presents enlargement of the abdo- 
men due to dilatation of the colon but this is a congenital 
affection, and a history of obstinate constipation with enlarge- 
ment of the abdomen dating back to early infancy can be 
obtained. Furthermore, in Hirschsprung's disease there is 
hypertrophy as well as dilation and the thickened walls of the 
colon can be distinctly felt while peristaltic waves are usually 
clearly visible. 

In older children it is important to eliminate other diseases 
such as chronic appendicitis, tuberculosis, focal infections and 
intestinal parasites in the diagnosis of a primary digestive 
derangement. The X-ray is of the greatest value in demon- 
strating the mechanical conditions which are responsible for 
many of these cases. 

Treatment . — The treatment must be both hygienic and 
dietetic. Since the digestive function is so largely dependent 
upon a good supply of blood and draws upon the energy of the 
organism to a large extent, fresh air and ample sleep are of 
great importance. These children are usually poor sleepers; 
they should therefore be made to rest at least half an hour after 
every meal. Proteins, especially beef-juice, finely minced rare 
meat and albumin milk (Eiweissmilch) are well born. Butter- 
milk is also a good food in these cases. Strained green vege- 
tables are useful and together with beef -juice help to overcome 
the anemia. Since fat and carbohydrate indigestion are the 
leading features of the majority of cases a high protein diet is, 
as a rule, useful. In cases with intestinal toxemia, especially 
constipated cases with stasis or ileocecal regurgitation and in 
cases of mucous colitis, a carbohydrate and vegetable diet must 
be employed. All cereals must be cooked for several hours and 
milk should be boiled. Often preparations like Dryco and 



114 DISEASES OF CHILDREN 

Malted Milk agree better than fresh milk. Zwieback is better 
digested than bread or toast. 

Irrigation of the bowels is of value in the cases with loose, 
offensive stools and constipation should be treated with massage 
and low enemata rather than with laxatives. Liquid paraffin 
is sometimes of distinct value in the constipated cases. 

An abdominal support will be required, for a time at least, 
in most cases. 

Cases in which constipation is present will be benefited by 
one of the following remedies, selected upon its characteristic 
symptoms : 

Calcarea carb. Eachitic and scrofulous children; fair com- 
plexion, tendency to perspire. Prominent abdomen; clay 
colored, putty-like stools. 

Carbo veg. Gastric flatulency; sour eructations; slow 
digestion. 

Hydrastis Canadensis. This is a good bitter tonic in small 
doses and is especially useful in chronic catarrhal affections of 
the gastrointestinal tract with atonic dyspepsia and constipation 
with mucus in the stools. 

Lycopodium. Lithemic cases; distended abdomen; hard 
constipated stools ; urine shows a brick dust deposit or uric acid 
crystals. Child has a capricious appetite and is very fretful. 

Mercurius vivus. Tongue heavily coated; foul breath; 
chronic nasopharyngeal catarrh ; slight enlargement of the liver ; 
pale, grayish stools. 

Nux vomica. Gastric symptoms predominate. Distress after 
eating; poor appetite; headache and nausea frequently occur. 
The child is nervous and fretful; abnormal appetite at times 
preceding attacks of indigestion ; recurring vomiting. 

When diarrhea is a characteristic! feature the following 
remedies will be called for : 

Calcarea phos. Anemia and malnutrition; sunken flabby 
abdomen ; green, slimy, fetid stools. 

Mercurius corrosivus. Dysenteric type of symptoms. Blood 



DISEASES OF THE GASTROINTESTINAL TRACT 115 

frequently present in the stools. The lower colon is chiefly 
involved. 

Magnesia carb. Sour, frothy stools containing large amounts 
of undigested fat particles. 

Phosphoric acid. Painless, watery stools; abdomen greatly 
distended. There is marked prostration and exhaustion. 

Sulphur. Chronic diarrhea, worse in the early morning 

hours. The stools are watery and irritating. Chronic skin 

affections are associated. 

ACIDOSIS. 

The term acidosis indicates a decrease of the alkaline reserve 
of the blood plasma. There are no characteristic clinical symp- 
toms to indicate such a condition until a dangerous degree of 
hydrogen-ion concentration of the blood has developed. Under 
these circumstances the characteristic breathing of air-hunger 
sets in ; the breath may betray the odor of acetone and coma even- 
tually develops. When acidosis has progressed to this stage it is 
usually beyond medical help. 

The earlier stages of acidosis and the compensated form must 
be diagnosed entirely by laboratory methods. The term 
"acidosis," being a catchy phrase, has unfortunately become a 
popular diagnosis and now occupies the place in medicine which 
such phrases as "uric acid diathesis" and "autointoxication" 
formerly held. Not that we wish to cast any reflections upon 
the validity of using the term acidosis in its proper place, 
however many conditions have been attributed to an acidosis 
without the slightest proof that such a condition was present. 
On the other hand, cases with a serious reduction in the blood 
bicarbonates, either due to renal insufficiency or to the accumu- 
lation of acetone bodies in the blood have been overlooked 
because the proper tests for determining this condition were 
not made. 

The important fact, then, to bear in mind in conjunction with 
acidosis, is that there are no reliable clinical signs upon which 
acidosis can be recognized until it has developed to a dangerous 



116 DISEASES OF CHILDREN 

point. We must therefore be thoroughly conversant with 
certain laboratory methods which are both practical and valu- 
able in the early recognition of an increase of acid radicals in 
the blood plasma. 

One of the simplest tests is that devised by Palmer and Hen- 
derson. This test is based upon the fact that when the normal 
buffer substances in the blood plasma, namely the bicarbonates 
and phosphates, are more or less exhausted by the accumulation 
of non-volatile acid substances in the blood, the individual's 
alkaline tolerance rises. In a normal individual four to five 
grams of bicarbonate of soda cause the reaction of the urine to 
become alkaline while in acidosis much larger quantities are 
required. 

Acidosis occurs when non-volatile acids, the result of <a 
perverted metabolism, accumulate in the blood beyond the point 
at which they can be promptly eliminated or neutralized by the 
buffer substances in the blood plasma. The commonest acids 
encountered in acidosis are the acetone bodies. These are 
derived from the fatty acids of the food fats, or in some cases 
from the body fats themselves, being intermediary products of 
incomplete combustion. Normally fats are oxidized into carbon 
dioxid and water; under certain abnormal conditions of carbo- 
hydrate metabolism, or in certain toxic states, the acetone bodies 
accumulate in the blood. The same thing may happen in carbo- 
hydrate starvation for it has been determined that "the fats are 
burned in the flame of carbohydrate combustion." This explains 
why acidosis frequently develops in a diabetic when he has been 
too abruptly deprived of carbohydrates. 

In the early stages of such an acidosis, acetone alone appears 
in the urine, since this substance is nearer to complete oxidation 
than the other acetone bodies and is therefore the first evidence 
of a failing combustion of fats. Acetonuria is frequently 
detected in febrile disturbances and digestive derangements and 
is not necessarily a serious condition. If the inability to oxidize 
fats, however, becomes still more pronounced then the more 



DISEASES OF THE GASTROINTESTINAL TRACT 117 

dangerous acetone bodies, namely aceto-acetic acid and oxy- 
butyric acid make their appearance and a serious increase of 
acid radicals with a corresponding decrease of carbon dioxid 
in the blood plasma occurs. When the H-ion concentration of 
the blood increases beyond a certain point there is a correspond- 
ing inability of the blood to take up carbon dioxid. Consequent- 
ly air hunger and increased respiration sets in, without, however, 
a cyanosis, as usually exists with the dyspnea of respiratory 
affections. 

With the development of such an acidosis from the production 
of acids in the process of metabolism, ammonia is formed for 
the purpose of restoring bicarbonate and alkaline phosphate 
from the products of the reaction of these substances with acids, 
or for the purpose of directly neutralizing acids. This ammonia 
is derived from the products of protein catabolism, these being 
utilized in the form of ammonia instead of being converted 
into urea. 

Another factor in combating the development of an acidosis 
is the conversion of alkaline phosphate into acid phosphate. 
This is excreted by the kidneys in excess of alkaline phosphate 
and thus tends to restore the alkalinity of the blood. 

Finally, an increased excretion of carbon dioxid by the lungs 
is brought into play. When the blood carbonates are reduced 
the respiratory center is stimulated, breathing is augmented 
and an increased elimination of C0 2 results. The decrease 
in carbonic acid may compensate for the increase of the non- 
volatile acids and an acidosis is thus averted for the time being. 
When, however, the alkaline reserve has been entirely depleted 
overstimulation of the respiratory center occurs with hyperpnea 
and a marked fall in the carbon dioxid tension of the alveolar 
air. If the alkaline reserve cannot be replenished at this stage 
the acidosis reaches a point which is incompatible with life. 

From the clinical standpoint we can recognize two degrees 
of acidosis and also two distinct clinical types. The commonest 
is the compensated form in which the excess of acid in the 



118 DISEASES OF CHILDREN 

organism is met by an increased excretion of acid sodium 
phosphate by the kidneys, an increased elimination of carbon 
dioxid by the lungs and the production of ammonia in the 
catabolism of nitrogenous foods. Such a condition can be 
demonstrated by laboratory methods but from the clinical 
standpoint it is not an acidosis. However, it may be converted 
into an active acidosis through the occurrence of an acute 
infection or an intestinal toxemia which break down for the time 
being the compensatory mechanism. In a child with a normal 
metabolism such factors would not be able to precipitate an 
acidosis. 

The nature of the metabolic disturbance underlying the 
development of attacks of acidosis is not understood. There are 
the indications of sub-oxidation and of intolerance for normal 
amounts of fat. There is also a prominent nervous factor in 
many cases and indications of chronic intestinal toxemia. The 
commonest dietetic error is overeating. Focal infection, espec- 
ially diseased tonsils and adenoids are commonly found in 
children who are prone to acidosis. A family predisposition 
is often noted. The acidosis which develops in infants as a 
complication of a severe diarrhea is due to the rapid loss of 
water and alkali through the intestines and the associated 
toxemia and renal insufficiency. 

There are two clinical types of acidosis ; the one is apparently 
a primary condition while the other occurs as a secondary 
manifestation of severe forms of infantile diarrhea or of cyclic 
vomiting. In both of the latter forms there is presumably a 
previous relative acidosis which is converted into an active, or 
manifest acidosis by the above mentioned disturbances. 

In speaking of "acidosis," or "acid intoxication" the first 
class of cases is usually implied. While the acidosis is the 
predominating clinical condition, still these patients almost 
invariably show evidence of an infection, usually of the upper 
respiratory type, preceding the symptoms of acidosis. No 
doubt the toxemia due to the infection is responsible for the 



DISEASES OF THE GASTROINTESTINAL TRACT 119 

increase of acetone bodies in the blood. In this respect the 
acidosis differs from that observed in cyclic vomiting and 
diarrhea in which cases it is of later occurrence and is due to the 
acute inanition, loss of body fluids and interference with the 
renal function. 

The characteristic symptoms are fever ranging from 102° to 
104° F. ; a mild type of tonsilitis or nasopharyngitis ; vomiting 
and hyperpnea. The degree of acidosis is usually mild but 
serious and fatal cases occur. There is a strong tendency to 
recurrence as in cyclic vomiting and frequently several children 
in the same family are affected. For treatment see "Cyclic 
Vomiting." 

CYCLIC, OR RECURRENT VOMITING. 

Cyclic vomiting is a condition in which periodic attacks of 
uncontrollable vomiting occur. It is most frequently encoun- 
tered in children between the ages of three and six years, the 
sexes being affected about equally. Persistent vomiting devel- 
oping in an infant should suggest the onset of tuberculous 
meningitis rather than this condition, although vomiting and 
acidosis may develop secondarily to a severe infantile diarrhea. 
Acidosis has in fact been looked upon as the cause of cyclic 
vomiting, owing to the fact that acetone and diacetic acid can 
usually be detected in the urine during an attack. The presence 
of the acetone bodies in th urine must, however, be looked upon 
as a secondary condition, because they are often absent at the 
time of the onset of the vomiting, sometimes not showing before 
the second or third day, and also because they are never present 
in large amount. 

The primary cause is no doubt a metabolic disturbance with 
diminished oxidation. This leads to the accumulation of unox- 
idized toxic substances in the blood. The nature of these 
substances is not known. In the severe types of cyclic vomiting 
albuminuria, casts, and a leucocystosis occur in conjunction 
with the vomiting. A derangement of the glycogenic function 
of the liver may be responsible for a disturbance in the oxidation 



120 DISEASES OF CHILDREN 

of the fats so that acetone, diacetic acid and oxybutyric acid 
appear in the blood as intermediary bodies of the incomplete 
catabolism of fats. It is evident that any factor which may 
upset the glycogenic and perhaps also the detoxicating function 
of the liver, can become an important indirect cause of an 
acidosis. Overeating, intestinal toxemia, nervous excitement or 
shock, over-fatigue, and bacterial toxemia are all to be considered 
in this light and their etiological relationship to cyclic vomiting 
is to be explained on these grounds. It is a common clinical 
observation that many children who are subject to these attacks 
have chronically infected tonsils and adenoids. An acute infec- 
tion in such a child will result in a more pronounced reaction 
than in a normal one and may thus precipitate an attack. 
Nervous excitement and fatigue also frequently precipitate an 
attack perhaps through the derangement of the delicate mechan- 
ism of the hepatic function which is under nervous control. 
Indeed, some clinicians have looked upon cyclic vomiting as 
a manifestation of hysteria because the nervous element plays 
such a prominent role in its etiology. Whether such a condi- 
tion as chronic appendicitis acts as a reflex cause or in the 
nature of a focal infection is difficult to decide. Personally I 
have seldom found symptoms referable to the appendix. Ker- 
ley believes that many cases of recurrent vomiting are due to 
a dilated or ptosed stomach in which there is retention and 
residue long after the feeding period as demonstrated by 
Roentgen-ray studies and that acidosis has nothing to do with 
their etiology. Personally I have encountered cases in which 
acidosis could be positively demonstrated while in others there 
was an absence of acetone bodies in the urine throughout the 
attack together with normal carbon dioxid tension of the alveolar 
air. It is indeed surprising that the more serious symptoms 
of acidosis are so seldom encountered in cyclic vomiting. No 
doubt the early onset of vomiting and the absolute fast which 
the patient is forced to undergo tends to bring about a spon- 
taneous cure of the case. The fact that the attack is self- 



DISEASES OF THE GASTROINTESTINAL TRACT 121 

limiting, the vomiting being uninfluenced by any mode of 
treatment, and that prompt recovery is the rule, tend to substan- 
tiate this belief. 

Symptoms. — Prodromal symptoms, such as anorexia, mal- 
aise and slight fever may be present, but they are frequently 
absent and the attack occurs abruptly after some form of nervous 
excitement or a "cold." 

Vomiting is the chief symptom, being persistent and appar- 
ently not traceable to acute indigestion. It usually continues for 
from two to three days, being little influenced by treatment. 
There is no pain and the abdomen is soft and retracted. Nausea 
is slight or absent. 

The bowels are constipated and the colon may be felt in a 
state of spastic contraction. The stools are sometimes light 
in color. As a rule there is no fever excepting in the early 
stages. 

The child's general condition may become alarming although 
convalescence is usually rapid and fatalities are rare. Pros- 
tration is marked and the child lies in an apathetic state suffer- 
ing intense thirst but unable to retain even a swallow of water. 
The tongue becomes dry, the lips are abnormally red, the eyes 
sunken, the respirations are shallow and the pulse is exceedingly 
rapid. Air-hunger does not occur in the milder cases but may 
become quite marked in the severe forms of the disease. The 
pupils and reflexes are normal and Kernig's sign or other 
evidence of meningeal irritation are never noted. A character- 
istic fruity odor can usually be detected on the breath, indicating 
the presence of acetone. At this stage the urine becomes scanty 
and contains varying amounts of acetone and diacetic acid. 

The milder cases subside at the end of forty-eight hours. 
They are generally encountered in neurotic children, coming on, 
as a rule, after overexertion, fright or excitement. Indiscretions 
in diet and neglect of the bowels may, of course, be preceding 
factors. 

Occasionally a more serious type is encountered in which the 



122 DISEASES OF CHILDREN 

vomiting may persist for from four to five days with the develop- 
ment of symptoms of acidosis and grave prostration. A fatal 
outcome occurs at times. The urine in these cases shows 
albumin, blood and casts beside the acetone bodies and the blood 
shows a leucocytosis. Hematemesis is usually present, adding 
to the gravity of the case. 

Diagnosis. — In mild cases a first attack may not be recog- 
nized as a distinctive type of vomiting but a recurrence in the 
course of several months without the history of a dietetic error 
should arouse suspicion of the true nature of the attack. 

'Simple nervous vomiting frequently occurs in nervous children 
after excitement or overexertion, but it is of short duration and 
there is only the vomiting of food. 

Acute gastric indigestion gives a history of an indiscretion 
in diet and the symptoms promptly improve after the stomach 
and bowel have been emptied while in recurring vomiting the 
retching and vomiting persist in spite of all treatment directed 
to the stomach ; in other words, it acts precisely as other forms 
of toxic vomiting, like the vomiting of pregnancy, for example. 

Appendicitis and intussusception can be excluded by making 
a careful abdominal examination, supplanted, if necessary, by 
a rectal examination. In intussusception we encounter a 
sausage-shaped tumor in the abdomen together with hyperactive 
peristalsis and often a bloody discharge from the rectum. In 
appendicitis there is fever and abdominal pain together with 
tenderness and rigidity over the appendix or a sensitive mass 
in the appendicular region. If septic peritonitis develops the 
abdomen becomes distended, peristalsis ceases and the pulse 
rate is disproportionately high. At this stage the vomiting may 
become stercoraceous, which it never does in recurrent vomiting. 

Tubercular meningitis, in the early stages, may closely sim- 
ulate the picture of recurring vomiting. There is the mental 
apathy; the vomiting without apparent cause and retracted, 
non-sensitive abdomen. The pulse and respirations are, how- 
ever, more irregular in meningitis; involvement of the ocular 



DISEASES OF THE GASTKOIKTESTIKAL TKACT 123 

muscles soon makes its appearance and Kernig's and Babinski's 
signs are found even in the early stages of most meningeal 
conditions. Finkelstein cautions against excluding brain affec- 
tions because of a history of previous attacks of vomiting, as 
such conditions may present repeated attacks of intracranial 
pressure with clear intervals. An examination of the eye- 
grounds is of great value in such cases. 

Acute nephritis cannot be ruled out at the height of an 
attack when albumin and casts are found plentifully in the 
urine, but the absence of edema and of suppression of urine 
and the rapid disappearance of the albumin and casts after the 
subsidence of the attack exclude a primary nephritis. 

Treatment. — Treatment between attacks should first be con- 
sidered. As these children are usually of a neurotic temperament 
and present evidence of defective elimination they must be kept 
on a diet in which milk, cereals, whole-wheat or bran bread, fresh 
vegetables, and fruit play the major role. Fat should be 
prohibited, and sugar and starch given sparingly, although not 
too rigidly excluded because of the importance of carbohydrates 
as heat-producing foods and their role in the metabolism of fats. 
Meat may be taken sparingly. The chief thing to guard against 
is overeating. Intestinal autointoxication is to be strictly 
prevented and whenever indican appears in the urine in excess 
the child should receive a saline laxative and an effort made 
to have it drink buttermilk instead of sweet milk. Systematic 
colon irrigation should be practiced in cases with iliac stasis. 

The administration of small doses of bicarbonate of soda 
— five grains three times daily, after meals — between attacks 
has proven of some value in lessening the frequency of the 
attack when the above dietetic precautions are observed. 

Remedies, such as calcarea carb., calc, phos., lycopodium, 
ignatia, arsenicum, etc. are useful in correcting chronic distur- 
bances in the digestive tract or nervous manifestations of long 
standing. A remedy which I have found useful in migraine 
in lessening the number of attacks and which is also applicable 



124 DISEASES OF CHILDREN 

to cyclic vomiting is sanguinaria which should be administered 
in doses of several drops of the tincture or lx dilution after 
meals. 

During the attack the child should be immediately put to bed 
in a quiet, partially darkened room and all food withheld for 
the first twenty-four hours. Cracked ice may be permitted and 
the child should be urged to take half a glass of water containing 
twenty grains of bicarbonate of soda. If this is vomited it 
should again be tried in an hour when it may possibly be re- 
tained. Should the second attempt fail, a few teaspoonfuls of 
the soda solution may be administered every half hour and if it 
is retained the amount may be increased. When, however, all 
attempts to give water or bicarbonate of soda by mouth result 
in vomiting, the best course to pursue is to discontinue every- 
thing by mouth and give normal salt solution by rectum. If 
the vomiting persists after the second day, three per cent of 
glucose may be added to the normal salt solution and given by 
enteroclysis. 

On the second or third day such foods as albumin water, 
peptonized milk, barley-water and strained rice broth may be 
attempted, given in small quantities at two hourly intervals. 
At times, a gruel, such as farina or cream of wheat, or solids 
like zwieback are better retained than liquids. 

Remedies. — Nux vomica and ipecac may be useful early in 
the attack. The indications for nux vomica are headache, nausea, 
constipation, coated tongue, delayed digestion (stasis) or ill 
effects of overeating. 

The indications for ipecac are chiefly the persistent vomiting 
without signs of a gastric disturbance. 

Small doses of calomel, %o to %o grain, every hour for 
ten doses at times relieve the vomiting and at the same time 
act as a mild purgative. 

Belladonna is useful when there is fever and when the attack 
is of nervous origin. 

Arsenicum is indicated in the severe forms of vomiting 
associated with albuminuria and marked prostration. 



DISEASES OF THE GASTROINTESTINAL TRACT 125 

Bromides, given by rectum, are also useful in the more severe 
type of cases. 

HYPERTROPHIC PYLORIC STENOSIS. 

Pyloric stenosis occurs in infancy as a result of a congenital 
hypertrophy of the musculature of the pylorus. The stenosis 
is progressive in development and may terminate in complete 
obstruction. The circular muscular fibres are mainly involved ; 
other pathological changes are wanting. Muscular spasm, no 
doubt, plays a part in the production of the pyloric obstruction 
and cases of pylorospasm unaccompanied by a hyperplastic 
tumor involving the pyloric muscle are by no means rare and 
must be considered in the diagnosis of pyloric stenosis. 

Pyloric stenosis is more frequently encountered in male than 
in female infants. It has no connection whatsoever with dys- 
pepsia or improper feeding; indeed the majority of cases appear 
to develop in breast-fed infants. The etiology is unknown; a 
family predisposition is noted in some cases. Two of my cases 
occurred in the same family. The condition is a congenital 
malformation probably atavistic in type. 

Symptoms. — The babe is usually well developed and well 
nourished at birth, nursing and gaining normally for a time. 
Vomiting is the chief symptom and the first one to call attention 
to the condition. It comes on more or less abruptly toward the 
end of the first month and gradually increases in severity and 
in persistency so that the child loses weight rapidly and the 
bowels become obstinately constipated. Enemata bring away 
bile-stained mucus but no milk residue. The food is naturally 
suspected of disagreeing with the infant but dietetic treatment 
exerts no influence upon the vomiting which now occurs prac- 
tically after every feeding and becomes projectile in type. 
Sometimes one feeding is retained but after the next feeding 
the combined amount of both is vomited. Vomiting is not 
accompanied by nausea or pain. The babe may vomit toward 
the end of a nursing and then eagerly seeks the nipple and 
nurses all over again. 



126 DISEASES OF CHILDREN 

Dilatation of the stomach gradually takes place together 
with hypertrophy. The epigastric region is prominent, espec- 
ially after nursing, while the lower abdomen is sunken and 
flaccid. The intestinal tract is practically empty. When the 
stomach is filled, peristaltic waves make their appearance due to 
the abnormal effort of the stomach to empty itself. These waves 
originate in the left hypochondriac region and cross the epi- 
gastrium to the region of the pylorus where they cease. The 
outline of the stomach is plainly indicated by these waves and 
we can observe from day to day the increasing gastric area. 

At this stage a small oval tumor about the size of a small 
olive can be demonstrated in the pyloric region in the majority 
of cases. The usual site is to the right of the median line, 
midway between the tip of the xiphoid and the umbilicus. It 
is most readily felt just after vomiting, at which time the 
abdomen is relaxed. 

Residual food is usually present in the stomach and this is 
a most important diagnostic sign. By inserting a No. 16 French 
soft rubber catheter into the stomach four hours after a feeding, 
an ounce or two of residual food can be aspirated, providing 
there has been no previous vomiting. The X-ray also shows the 
opaque meal still in the stomach and the cap and duodenum 
empty. 

The prognosis and ultimate outcome of cases of pyloric 
stenosis depend upon the degree of anatomical changes present 
in the pyloric region of the stomach and whether the symptoms 
are predominatingly mechanical or spasmodic in character. 
Owing to the difficulty of sharply differentiating hypertrophic 
stenosis from pylorospasm, confusion as to the prognosis nat- 
urally arises. Undoubtedly many cases of spasmodic pyloric 
stenosis have been mistaken for hypertrophic stenosis. Again, 
a case of hypertrophic stenosis may at times present more spasm 
than actual anatomic obstruction and so recover under medical 
treatment. Cases, however, which show an absolutely unyield- 
ing obstruction at the pylorus and in which a tumor can be 
distinctly felt, do not yield to any but surgical treatment. 



DISEASES OF THE GASTROINTESTINAL TRACT 127 

The diagnosis of pyloric stenosis rests upon the history, the 
persistent projectile vomiting, the gastric dilatation with vis- 
ible epigastric waves and the progressive rapid emaciation of 
the infant. The first symptom is vomiting, setting in abruptly 
in an infant from two to four weeks old without assignable 
cause. Associated with the vomiting is obstinate constipation 
and scanty urine and loss of weight. There is no evidence of 
nausea or pain and dietetic treatment does not influence the 
vomiting. 

Pylorospasm is differentiated by the irregularity in the 
character of the vomiting, the fact that food still passes into 
the intestines as shown both by the character of the stools and 
by the X-ray plates. A tumor can at times be felt in spasmodic 
cases due to spastic contraction of the pylorus, but this disap- 
pears after vomiting or after gastric lavage. Furthermore, 
medical and dietetic treatment bring results which are not seen 
in hypertrophic stenosis. 

Treatment. — The early treatment of the vomiting is that 
of dyspeptic vomiting. Milk should be discontinued for a time, 
and whey, barley-water, and albumin-water may be tried. Lav- 
age should be systematically carried out. The stomach should 
be thoroughly washed out once or twice daily with a warm 
solution of bicarbonate of soda, one drachm to the pint, for 
the purpose of removing all food residue and to wash out the 
mucus. The child should be nursed at four hour intervals and 
heat applied to the epigastrium after each feeding. The child 
should be placed on its right side with the head slightly elevated. 
If, in spite of these measures, breast milk is not retained we 
should try the thick farina treatment advocated by Sauer of 
Chicago, (Archives of Pediatrics, July, 1918). 

The formula recommended by Sauer is made up as follows : 

Skimmed milk 9 oz. 

Water 12 oz. 

Farina 6 tablespoonfuls. 

Dextri-^Maltose 3 tablespoonfuls. 

Boiled for one hour in a double boiler. 



128 DISEASES OF CHILDREN 

At each feeding the required amount should be warmed and 
then administered on the end of a spoon handle. The infant 
may be slow in swallowing the thick paste and it sometimes 
takes an hour to give the required amount. Two to three ounces 
may be fed every four hours. As a rule, the infant soon learns 
to take the food and a little patience is all that is required to 
carry out the treatment. The results are most gratifying in 
many instances. It is the only form of medical treatment which 
offers any hope of averting an operation in true cases of stenosis 
and should be tried on all cases that are seen early. 

Sauer has demonstrated by X-ray studies that the patency of 
the pylorus is much greater after cereal feedings than it is 
after a milk-mixture feeding. There is therefore a prompt 
return of food residue in the intestinal contents in all cases 
which respond to this treatment. Should, however, the vomiting 
and constipation persist and the infant continue to lose weight, 
surgical interference becomes imperative. 

The operation of choice is Rammstedt's pyloroplasty. The 
technique is simple but the operation is a delicate one and 
requires skill and experience. Gastroenterostomy has been 
abandoned by most surgeons. The technique presents many 
difficulties, the surgical shock is great and the mortality high. 
My experience has been very discouraging with this operation. 
With the Rammstedt operation, however, the surgical risk is 
small. The operation is of short duration and not accompanied 
by shock. The results are brilliant ; vomiting usually ceases at 
once and so far there has been no return of the stenosis in any 
of my cases. 

DIARRHEA. 

There are two clinical types of diarrhea encountered in 
infancy, one of which is due to some error in feeding or to 
the activity of saprophytic bacteria in the intestinal tract, 
while the other results from the action of bacteria which are 
either primarily pathogenic or which are capable of producing 
toxic substances in the intestines. The first group comprises 



DISEASES OF THE GASTROINTESTINAL TRACT 129 

the class of cases which are usually described under the headings 
of dyspeptic diarrhea, fermental diarrhea and acute intestinal 
indigestion, while the second group embraces the various clinical 
types of the so-called "Infectious Diarrheas" 

DYSPEPTIC DIARRHEA; ACUTE INTESTINAL INDIGESTION. 

Dyspeptic diarrhea is the commonest and least serious of 
the acute intestinal disorders of infancy. It is a frequent mani- 
festation of overfeeding. Hot weather and teething are predis- 
posing factors, but an infant may develop diarrhea at any time 
of the year if it is fed too often or too much at a time or given 
a formula with an excess of sugar. Cane sugar and sugar of 
milk cause diarrhea more readily than one of the maltose 
preparations, while raw milk is more likely to induce it than 
boiled milk. 

In cases of diarrhea due to fat indigestion the infant usually 
regurgitates excessively and the stools contain small, soft 
fat curds. 

Sugar dyspepsia produces acid, excoriating stools, often green 
in color or soon changing to green on exposure to air. In protein 
indigestion the stools are yellow or brown, offensive, and con- 
tain tough casein curds. Curds do not occur when boiled milk 
is used. Milk that has not been properly kept but which is 
just on the point of turning sour may produce a severe dyspep- 
tic diarrhea. 

Symptoms. — The cardinal symptoms are colicky pains, 
intestinal fermentation and loose stools. Moderate fever is 
usually present. The number of stools is seldom more than five 
to six daily. When the condition is one mainly of sugar fermen- 
tation they are green in color, acid in reaction and excoriating 
to the buttox. They are usually liquid and expelled with 
considerable gas. When the condition is due to proteolytic 
bacteria the stools are foul, alkaline in reaction and of a brown- 
ish color. When raw milk has been fed the stools frequently 

contain tough casein curds. 
10 



130 DISEASES OF CHILDREN 

The duration is short; fever and constitutional symptoms 
are usually slight or absent. A previously healthy child prompt- 
ly responds to proper dietetic treatment but one whose vitality 
has been depressed by hot weather may develop serious toxic 
symptoms as the result of a dyspeptic attack. Again, repeated 
attacks of dyspepsia eventually lead to impairment of nutrition 
and may thus predispose to the development of one of the 
nutritional diseases, such as rickets and scurvy. For this reason 
the importance of dyspepsia must not be underestimated. 

If the diarrhea continues for several days the buttox may 
become excoriated from the lactic and other lower fatty acids in 
the stool. Mucus may also appear in the stool as a result of 
irritation of the intestinal mucosa. The urine becomes am- 
moniacal and irritating to the skin. 

Diagnosis. — The short duration, slight fever or absence of 
fever, and the character of the stools differentiating simple 
diarrhea from infectious diarrhea. In hot weather infants 
frequently have watery, yellowish stools due to the enervating 
effect of heat and humidity upon the nerves controlling the 
secretions and movements of the intestines. 

The diarrhea ushering in one of the acute infectious fevers 
can only be identified by the ultimate appearance of the symp- 
toms peculiar to the affection in progress. 

Treatment. — Treatment is mainly prophylactic. Starchy 
foods should not be fed to young infants excepting in weak 
solution, such as barley water, or dextrinized gruels. Infants 
whose digestive powers are naturally weak should be fed on 
proportionately weaker milk formula than robust infants of 
the same age. During hot weather the fat and sugar should be 
reduced and it may become necessary to boil the milk in order 
to prevent the formation of casein curds. 

During an attack it is advisable to withhold the usual food 
for from twelve to twenty-four hours, as necessary, and admin- 
ister simply boiled water, weak tea, or barley water. On the 
second day one part skimmed-milk to two parts of barley water, 



DISEASES OF THE GASTROINTESTINAL TRACT 131 

mixed and boiled for three minutes, may be tried. If this agrees, 
whole milk should be substituted for skimmed milk. Sugar 
should be withheld from the food until all signs of indigestion 
have disappeared. (See Treatment of Infectious Diarrhea, 
p. 143). 

In the diarrheas accompanying teething, or those of a neurotic 
type, such remedies as Belladonna, Chamomilla, the Calcareas 
and Pulsatilla are the ones usually indicated. For simple 
dyspeptic diarrhea Nux vomica 3x is the best remedy. Mer- 
curius 6x is preferable when there is much mucus in the stools 
and if the buttox becomes excoriated. China 2x is useful in 
atonic diarrhea of hot weather. 

Aloes. — Flatulence and rumbling in the lower bowels; large 
quantities of gas escape with stool. 

Bell. — During hot weather and dentition; face flushed, ab- 
domen distended, colicky pains; cerebral symptoms; skin hot 
and dry. 

Bry. — Diarrhea from sudden changes in the weather, espec- 
ially when there are hot days and cold nights. Diarrhea worse 
mornings, painful, aggravation from motion. 

Calc. carb. — Diarrhea during dentition; rachitic infants; 
profuse sweating about head; distended abdomen; vomiting 
and diarrhea. Stools sour and undigested. 

Calc. phos. — Dentition delayed; recurring attacks; stools 
green, with mucus; abdomen flaccid. 

Cham. — Dentition; painful, excoriating diarrhea, looking 
like spinach and eggs. Child cross and irritable; wants to 
be carried. 

China. — Undigested stools; flatulent colic, or painless stool 
with much fermentation. Anaemia and prostration; loose, 
yellowish stools in hot weather. 

Colocynth. — Pain relieved by firm pressure. 

Ipecac. — Green, loose stools associated with vomiting. 

Mag. carb. — Stools green and frothy, like frog-pond scum, 
containing tallow-like lumps. Sour odor ; colic relieved by stool ; 
fat diarrhea. 



132 DISEASES OF CHILDREN 

Mercurius. — "It is better indicated the more widely in the 
departure from the natural color of the motions, and the more 
slimy they are." — (Hughes.) 

Nux vomica, — Acute intestinal indigestion. In the beginning 
before inflammatory reaction has been set up and when the 
stools are still strictly dyspeptic in character. Associated 
gastric dyspepsia. 

Podophyllum. — More severe forms of diarrhea. The stools 
are yellow and watery and are expelled with much gas. Pro- 
lapsus ani. 

INFECTIOUS DIARRHEA 

(acute catarrhal enteritis; cholera infantum; 

ileocolitis.) 

The term "Infectious Diarrhea" is applied to those acute 
intestinal disturbances which can be traced directly to the action 
of bacteria or their toxins upon the mucous membrane of the 
intestines with resulting inflammatory reaction, diarrhea, fever, 
and toxemia. In this respect it differs specifically from simple 
diarrhea, or dyspepsia, a purely functional or chemical distur- 
bance, without inflammatory reaction in the gut and toxic 
manifestations. 

An inflammatory diarrhea is, however, not always infectious 
in the restricted sense of that term. With the exception of the 
cases of acute ileocolitis presenting characteristic dysenteric 
symptoms and in which the bacillus dysenterise can be found in 
the stools, we have no definite knowledge of the bacteriology of 
enteritis in infancy. It is true, an enteritis may result from 
infection of the alimentary tract with bacteria which are capable 
of setting up local inflammation in other mucous membranes, 
namely, the nose and throat or bronchi and it is not at all im- 
probable that streptococci, the pneumococcus and the influenza 
bacillus occasionally induce an enteritis. Such infections, 
however, are most common in the winter, a time when enteritis 
is rare. Streptococci are frequently found in the walls of the 
intestines in fatal cases, but are most likely secondary invaders. 

It is also probable that an excessive number of bacteria, not 



DISEASES OF THE GASTROINTESTINAL TRACT 133 

necessarily pathogenic, entering with the food or developing 
in the intestinal tract as a result of lowered vitality and dyspep- 
tic conditions, may set up an inflammatory reaction. This can 
result either from the action of bacterial toxins or from the 
irritating and toxic effects of products of bacterial decomposi- 
tion of the intestinal contents. Absorption of these toxic 
products explains the associated fever and toxemia. Whether 
such bacteria as the gas bacillus of Welch and the bacillus 
pyocyaneus play an active role in the cases in which they can 
be demonstrated in the stools, or are purely accidental has not 
been finally decided. 

Infantile diarrhea is so distinctly a disease of hot weather 
that the effect of prolonged heat and humidity upon the infant's 
metabolism and digestion is now almost universally accepted 
by pediatrists as the primary cause of the intestinal disturbances 
embraced by the term "infectious diarrhea." 

Finkelstein advanced the theory that the diarrhea and accom- 
panying toxic symptoms result from the injurious effect of the 
sugar in the food, in a child whose intestinal mucosa was 
previously injured by attacks of dyspepsia and whose vitality 
had been depressed by hot weather. The sugar is absorbed 
directly into the circulation, producing pyrexia and intoxication, 
and can be demonstrated in the urine. A high fat content of 
the food favors the development of this "Alimentary Intoxica- 
tion." The salts of the whey have also been shown to produce 
pyrexia and diarrhea. Czerny and Keller attributed the toxic 
manifestations to the bacterial decomposition of the food either 
before ingestion or later in the intestinal tract. They believed 
the toxic substances to be derived from the fat in the food, this 
being split into irritating lower fatty acids. The local action 
of these noxious substances results in an enteritis, while their 
absorption into the circulation, in conjunction with the depleting 
effect of the diarrhea, may induce an acidosis. Some of the 
symptoms which were formerly looked upon as toxic manifesta- 
tions are now recognized as being due to acidosis. 



134 DISEASES OF CHILDREN 

The work of Vaughan with protein split products and his 
discovery of a protein poison common to all proteins whether 
bacterial or food-proteins, has shed much light upon the patho- 
genesy of fever and other symptoms of infection. Some of 
these observations seem to fit in well with the clinical manifes- 
tations of infectious diarrhea. For example, as a result of 
incomplete digestion, a protein may be absorbed into the circu- 
lation in the form of peptone, the stage of digestion at which 
a protein becomes poisonous (Vaughan). Again, undigested 
protein may be absorbed from the alimentary tract, in dyspeptic 
conditions. This may be facilitated by the effect of excessive 
heat upon the infant's vitality and digestion and in this way 
some cases of cholera infantum might be explained. The fact 
that sugar is found in the urine, as pointed out by Finkelstein, 
does not weigh against this theory because albumin is also 
frequently present in the urine and the blood shows a pro- 
nounced leucocytosis. 

Bacteria, whether pathogenic or non-pathogenic, can split 
the proteins of the milk and probably render them absorbable 
without complete digestion, with resulting acute gastrointestinal 
symptoms of sudden onset after taking "spoiled milk." These 
cases are commonly designated acute milk infection. 

Food. — The importance of food as an etiological factor is 
only secondary to that of temperature and humidity. Children 
that are exclusively breast-fed rarely develop enteritis and then 
probably only through lack of hygienic care. The vast majority 
of cases occur in infants that are artificially fed and whose 
food, both as to the quality of the milk and the proper modifica- 
tion of the same, is decidedly below standard. It is always safer 
to use pasteurized or boiled milk in the summer. Cold weather 
seems to give a surprising immunity to diarrheal affections 
even when the quality of the milk is none too good. The 
investigation of the Rockefeller Institute into the etiology of 
infantile diarrhea disclosed the rather startling fact that despite 
the large number of bacteria that were found in many samples 



DISEASES OF THE GASTROINTESTINAL TRACT 135 

of milk fed to infants in the winter they exhibited a remarkable 
tolerance for the same. The practice of boiling milk and nsing 
pasteurized milk, now becoming more general among all classes, 
has done much toward reducing the infantile death-rate during 
the summer months. 

The environment is an important factor. Fresh air and 
personal cleanliness are two of the strongest prophylactic meas- 
ures in infantile diarrhea and when infants are kept in squalid, 
poorly ventilated or crowded quarters and not regularly bathed 
they offer poor resistance against an intestinal infection. 

Intestinal indigestion predisposes to the development of an 
infectious diarrhea. All dyspeptic conditions should, therefore, 
receive prompt attention. 

Pathology. — Both local and general pathological changes 
can be demonstrated in fatal cases. The body is emaciated in 
appearance due to the great loss of weight from demineralization 
of the tissues with consequent loss of water. Metabolic dis- 
turbances frequently demonstrable during life are sugar, ace- 
tone, and diacetic acid in the urine and increased urinary 
ammonia. Albuminuria, due to acute parenchymatous degen- 
eration of the kidneys is common. The blood shows a leu- 
cocytosis. 

The liver is enlarged due to fatty changes. Parenchymatous 
degeneration may be present. The lungs show hypostatic con- 
gestion and a secondary bronchopneumonia is common. 

In rapidly fatal cases of cholera infantum the gut may show 
no gross lesions but microscopic examination will reveal de- 
generative changes in the epithelial cells of the superficial 
layers of the intestinal mucosa. Typical cases of catarrhal 
gastro-enteritis present acute inflammatory reaction in the gas- 
trointestinal mucosa. The mucous membrane is congested and 
covered with mucus. The lymph follicles are swollen but not 
as markedly as in cases of ileocolitis due to dysentery bacillus 
infection. In protracted cases irregular superficial ulcers form 
on the intestinal mucosa. 



136 DISEASES OF CHILDREN 

Symptoms. — The symptoms of infectious diarrhea naturally 
vary with the physical condition of the infant at the time it 
is attacked and the severity of the pathological process active 
in the intestine. Cases of dysentery bacillus infection (ileoco- 
litis) present a characteristic train of symptoms and specific 
pathological changes in the gut and are therefore described 
separately. 

A typical case of enteritis usually begins with vomiting, 
fever, colicky pains and dyspeptic stools. The abdomen is 
distended with gas and the stools are at first acid and contain 
curds until the bowels have been thoroughly emptied. If no 
change is made in the diet at this time the acrid character of 
the stools may persist and the buttox become excoriated. When 
milk, however, is promptly withdrawn and carbohydrates are 
also withheld, then the fermentative changes in the gut are re- 
placed by putrefaction and the stool becomes offensive and 
alkaline in reaction. 

Associated symptoms are fever, prostration, gastric irritabil- 
ity and rapid loss of weight. A leucocytosis is usually present 
and albumin may be found in the urine. Eestlessness, nervous 
irritability, or drowsiness and collapsic symptoms may develop. 
In the more severe form, serious symptoms of intoxication develop 
and sugar may be found in the urine. 

As the condition advances the stools become more frequent 
and watery, the odor is putrid and mucus is present in appreci- 
able amounts. The color is either brownish or green; when 
putrefaction predominates they are brown, foul, watery and 
alkaline in reaction. Gas is passed freely with the stools. This 
is usually formed from the carbohydrates which are being 
rapidly fermented by the abnormal bacterial activity in the gut. 
Kendall has shown that the colon bacillus is a facultative 
organism capable of inducing either putrefactive or fermen- 
tative changes depending upon the nature of the medium in 
which it is growing. In symbiosis with the bacillus subtilis 
it is capable of generating large amounts of gas even in a 
protein medium. 



DISEASES OF THE GASTROINTESTINAL TRACT 137 

The duration depends to a large extent upon prompt rational 
treatment and also upon the child's physical condition at the 
time of onset of the attack. It will also be influenced largely by 
the severity of the initial symptoms. Many cases can un- 
doubtedly be aborted. The prompt disappearance of alarming 
general symptoms together with the vomiting and diarrhea 
which frequently follows upon the early institution of a star- 
vation diet and purgation or bowel irrigation, has convinced 
many pediatrists that these cases are purely toxic and not 
infectious in nature. While this is undoubtedly true in many 
instances, still there is a large percentage of cases which run 
their course, similar to any other infection, in spite of the above 
mentioned treatment. 

Cases that have gotten well under way before the offending 
food has been discontinued, or whose intestinal mucosa has been 
damaged by previous dyspeptic conditions, may continue to 
have watery stools with mucus and run a temperature for an in- 
definite period. In these instances bacteria have very likely 
penetrated the intestinal mucosa and have also been carried into 
the general circulation. It may, therefore, be stated that in 
the average case the fever will last from three to four days, 
provided the child receives prompt treatment and its physical 
condition before the attack was favorable. The diarrhea may, 
however, last longer and a tendency to relapse often exists for 
some time, necessitating great caution in the feeding of these 
cases. If the infant's condition was poor previous to the attack 
the reparative process will require a longer time and fever and 
diarrhea may persist for a week or two. A persisting fever is 
a grave prognostic omen as it usually signifies a secondary 
infection or a complication such as bronchopneumonia. 

Cholera infantum is a hyperacute type of gastro-enteritis, 
usually occurring in infants with previous intestinal disturb- 
ances and is rarely seen excepting during extreme hot spells. 
In some cases it may be due to an acute milk infection, or it may 
be a form of heat stroke. 



138 DISEASES OF CHILDREN 

The child is attacked suddenly with severe, repeated vomiting, 
high fever and diarrhea. The stools are profuse and watery in 
character, at first foul, later becoming like water and almost 
odorless. Rapid loss of weight and collapse follow. 

The child becomes semi-conscious, the eyes are sunken and 
there may be an apathetic staring expression. Sometimes the 
child becomes very irritable, the neck may be retracted and 
convulsions set in (hydrocephaloid state). 

The symptoms described by Finkelstein as acute alimentary 
intoxication are due to the development of an acidosis as pointed 
out by Howland. The child becomes drowsy and is only semi- 
conscious. When aroused it looks about with a vacant 
stare. The respirations are deep and rapid, due to air hunger, 
and may suggest pneumonia. The urine contains acetone and 
diacetic acid and may show traces of sugar. The prognosis in 
cholera infantum and in acidosis is always grave. 

Diagnosis. — At the time of the onset of a case of infectious 
diarrhea it is not always possible to determine whether we are 
dealing with a primary gastrointestinal condition or whether 
the diarrhea and vomiting are symptomatic of some other acute 
infectious disease. During hot weather, however, this doubt 
rarely arises. A fever and diarrhea that does not promptly 
respond to appropriate treatment is not likely to be a primary 
gastrointestinal affection. 

The severe nervous disturbances encountered in cholera in- 
fantum and in acidosis may suggest meningitis. The initial 
diarrhea, however, should rule out meningitis. When a case of 
enteritis presents a continued fever some complication such as 
otitis, bronchopneumonia and pyelitis should be looked for. 

ACUTE ILEOCOLITIS; DYSENTERY 
Acute ileocolitis is an acute intestinal inflammation due to 
infection with the dysentery bacillus in which characteristic 
lesions are produced in the lower portion of the ileum and in the 
colon. The clinical symptoms are continued fever with toxemia 
and diarrhea. 



DISEASES OF THE GASTROINTESTINAL TRACT 139 

The dysentery group of bacilli are the only organisms which 
have been found definitely associated with a specific intestinal 
infection in infancy. The "acid type," or the Flexner-Harris 
type is the organism most frequently found in this country. 
In some cases of ileocolitis streptococci are found in the stools 
in large numbers and it is possible that these organisms may 
set up an ileocolitis, on account of their special predilection for 
lymphoid tissue. The streptococcus is, however, generally looked 
upon as a secondary invader. 

In mild cases the mucous membrane of the lower ileum and 
more or less of the entire colon appears congested and swollen. 
In the small intestine the congestion usually appears in streaks 
on the folds of the mucosa which are seen to run transverse to 
the long axis of the gut as it is laid open for inspection. The 
small intestine is distended with gas and filled with undigested 
food and greenish mucus, which adheres to the surface. In cases 
of short duration the colon does not show as pronounced changes 
as the ileum, but in protracted cases it is always more affected. 

In more severe cases the deeper structures are involved, 
as a result of which there is slight thickening of the intestinal 
wall from round cell infiltration of the sub-mucosa. The lymph- 
oid structures are swollen and there is congestion about Pyer's 
patches ; the latter may stand out prominently, but they seldom 
ulcerate as in typhoid fever. The lymph follicles of the colon 
show the greatest involvement and they stand out on the mucous 
membrane as small beads — follicular enteritis. When the pro- 
cess has been a protracted one the follicles ulcerate. In severe 
catarrhal ileocolitis ulceration is more likely to take place 
irrespective of the lymph follicles and results in the production 
of variously sized, irregular, superficially situated areas 
(catarrhal ulceration). Hemorrhage does not result from 
such ulcers but they offer a port of entry for the development 
of a general bacterial infection and they always tend to protract 
the case if they do not hasten the death of the child. 

Microscopic examination shows destruction of the superficial 



140 DISEASES OF CHILDREN 

epithelial layer and round-cell infiltration of the mucosa. The 
blood vessels are engorged and the lymphoid structures swollen. 
In milk cases the process stops here. In severe cases the 
infiltration reaches to the muscular layers and necrotic changes 
take place in the inflamed follicles. The epithelium is densely 
infiltrated with leucocytes and fibrinous exudate can be demon- 
strated. This is but a step to the membranous variety. 

Membranous colitis presents the most pronounced anatomic 
changes. It corresponds closely to dysentery as seen in adults, 
but the membrane is not so thick and ulceration does not occur 
so extensively. The membrane is practically limited to the 
colon, its ascending portion and the sigmoid flexure being 
favorite sites. The membrane is of a dirty-gray color and closely 
adherent to the mucous membrane contrasting markedly with 
the deep red congestion of the latter where there is no membrane. 
The main changes are found in the intestinal wall, which is 
considerably thickened and rigid. Membrane may extend down 
as far as the rectum, where it can be seen during life as the 
child strains at stool. 

Follicular ulceration is not uncommon in cases that have run 
a protracted course. It is especially prevalent in institutional 
cases and among poorly nourished infants that have suffered 
from repeated attacks of enteritis. 

The ulcers are round, varying in size from a pin point to 
that of a split pea and represent destruction and excavation of 
the inflamed solitary follicles. They may be found in both the 
ileum and colon, but most frequently they are confined to 
the colon. 

In association with the distinctive lesions of ileocolitis it is 
not uncommon to find bronchopneumonia as a complication, 
which, in fact, may prove to be the determining cause of death. 
It is usually of the desquamative type; rarely septic, although 
a general infection from the intestines is possible. 

In the kidneys we may find evidence of acute parenchymatous 
degeneration. Acute nephritis is rare. Similar changes may 



DISEASES OF THE GASTEOINTESTINAL TEACT 141 

be observed in the liver. The mesenteric glands are usually 
enlarged. 

Symptoms. — A case of mild catarrhal ileocolitis begins with 
fever, diarrhea, and at times vomiting. It cannot be distin- 
guished from other forms of diarrhea until mucus and blood 
make their appearance in the stools. Instead of the symptoms 
abating after the intestinal tract has been emptied, there is 
a persistence of the same and the child continues to have 
small, frequent odorless dejecta consisting in the main of mucus. 
The abdomen is not distended as in fermental diarrhea but may 
be soft and sunken. 

As the case advances the stools become more irregular. Some 
are large, containing mucus, undigested food particles and 
serum in abundance while again others are simply a stain of 
mucus on the diaper as a result of the tenesmus that plays so 
prominent a role in ileocolitis. On account of this straining 
there is a strong tendency to the development of prolapsus ani. 

The constitutional symptoms are fever of moderate grade, 
with diurnal variations ranging from 100° to 102° F., although 
at the onset it may be much higher for a short period; pros- 
tration; loss of appetite and in some cases vomiting. The 
duration of the acute symptoms is about a week. Convalescence 
is slow and is characterized by a tendency to recurrence of 
mucus in the stools as soon as we attempt to put the child back 
on its customary diet. 

Severe catarrhal ileocolitis presents symptoms that have much 
in common with dysentery. Constitutional symptoms are 
pronounced. The fever is high throughout the entire course of 
the disease and the stools are frequent, are accompanied by 
painful straining and consist mainly of bloody mucus. 

Prostration and nervous symptoms are marked. The child 
presents the picture of a severe infection — dry, coated tongue; 
cracked, bleeding lips; apathy or great irritability; anorexia 
and thirst; prostration. The prognosis is grave; if recovery 
takes place we may look for a protracted convalescence on 



142 DISEASES OF CHILDREN 

account of superficial ulceration of the gut. The duration is 
from two to three weeks. Death usually occurs during the 
second or third week in fatal cases as a result of exhaustion, 
general sepsis or a secondary bronchopneumonia. 

Follicular ulceration is to be suspected in children of weakly 
constitution who have had repeated attacks of diarrhea or a 
protracted ileocolitis, and who continue to have a moderate fever 
and persistent mucus in the stools. The accompanying symp- 
toms are progressive emaciation and failure of strength; 
anorexia; bed sores; thrush, etc. The duration is long; the 
condition is practically a sub-acute one. The course is marked 
by improvement and exacerbation and may be protracted for 
two to three months. Even after the ulcers have healed there is 
persistent indigestion and tendency to diarrhea for some time. 
The characteristic symptoms may be summed up as continued 
loose movements, four to eight daily, consisting chiefly of green- 
ish mucus; slight fever; emaciation; absence of blood in 
the stools. 

Membraneous Colitis. — This severe and rare form of 
enteritis may present the most uncharacteristic symptoms; 
indeed, we may fail to recognize the intestinal condition early 
in the attack owing to the predominance of the toxemia. 

When the onset is abrupt and accompanied by cerebral 
symptoms it closely simulates meningitis. High fever; convul- 
sions ; retraction of the head and abdomen ; vomiting and stupor 
may be present for several days before our attention will be 
directed to the intestines by the appearance of bloody stools and 
probably prolapsus ani. 

The majority of cases, however, simulate severe catarrhal 
ileocolitis with the exception that shreds of membrane appear 
in the stools and may be seen at times upon the rectal mucosa 
during prolapsus. In all doubtful cases the stools should be 
carefully washed and strained, as it is difficult to distinguish 
membrane from mucus when the latter is abundant. 

The course is protracted and the prognosis is grave. 



DISEASES OF THE GASTROINTESTINAL TRACT 143 

The diagnosis rests upon the evidence of severe inflam- 
mation of the large intestine, especially of the descending 
portion. The characteristic symptoms are continued high 
fever and prostration; frequent, small stools consisting mainly 
of blood and mucus, with shreds of membrane in the stools. 
There is tenderness along the entire course of the colon, but 
particularly along its decending portion. In typhoid fever 
tenderness is only found in the ileo-cecal region and the stools 
are large, consisting mainly of the contents of the small intestine. 

In meningitis the bowels are constipated and the cerebral 
symptoms progress in regular order from day to day. In 
dysentery they are purely toxic and therefore vary ; in fact, they 
may improve, while the intestinal symptoms increase in severity. 

Pain, tenesmus, vomiting and prostration may suggest intus- 
susception, but in this condition the onset is abrupt, there is 
no fever, and an abdominal tumor may be demonstrated. 

Treatment. — The first and most important factor in the 
treatment of the infectious diarrheas is prophylaxis. This 
begins with the care of the child, especially during hot weather. 
Overdressing must be avoided and the child should receive an 
abundance of fresh air. The feeding must be intelligently 
supervised and all attacks of dyspepsia should receive prompt 
attention. 

The disinfection of the stools is important as not infrequently 
diarrhea becomes epidemic in a family, or hospital ward. 

The supervision of the food is of the greatest importance. 
Use only fresh, clean milk. Boil the drinking water for the 
baby. Pasteurization will not make dirty milk wholesome. 
If chemical changes have occurred in the milk, sterilization will 
not overcome them. Another important point in prophylaxis is 
not to wean an infant during the summer. There are times 
when this becomes necessary, but whenever at all possible we 
should wait for the advent of cool weather before taking 
this step. 

In the summer no infant should be kept in the city if it is 
at all possible to take it to the country or seashore. 



144 DISEASES OF CHILDREN 

Bathing is most essential during hot weather. The cool or 
tepid bath is absolutely necessary when fever is present; this 
may be given three to four times a day. 

As a matter of precaution it is safer to pasteurize all milk, 
even the best obtainable, during the hot summer months. The 
nipples should be boiled every day and the bottles filled with 
hot water and washing soda as soon as emptied. Before they 
are refilled they should be cleansed with a bottle-brush and 
thoroughly rinsed with plain hot water. 

In hot weather infants should receive an ounce or two of 
water, previously boiled and then cooled, several times daily. 

An important point to bear in mind is that during hot 
weather an infant cannot take as strong a milk mixture as 
during cold weather. It will usually take the same quantity 
because it is thirsty, but unless we cut down the fat and sugar 
we may set up a severe indigestion. Do not expect an infant 
to gain steadily during July and August. 

When diarrhea develops we must at once make appropriate 
changes in the feeding. In a breast-fed infant, in the absence 
of fever and vomiting, we may for a day or two continue with 
the breast milk, but lengthen the interval between nursings. 
Should the condition not improve it will be wise to alternate 
the breast with a bottle of barley-water and thus give the 
digestive organs a rest. 

The reason why milk is discontinued in the diarrhea of 
infants is because it acts as a good culture medium for the 
intestinal bacteria. According to Finkelstein, it is especially 
the lactose and the salts of the whey which are the offending 
elements. On the other hand, the casein of the milk, largely on 
account of its high calcium content, seems to exert an inhibitory 
effect upon the fermentative changes present in the gut in so 
many of the cases of summer diarrhea. Albumin-milk, there- 
fore, frequently proves to be a most successful diet for infantile 
diarrhea. 

The chief need of the organism during the first twenty-four 



DISEASES OF THE GASTROINTESTINAL TRACT 145 

hours of the illness is water and not food. This should be 
plentifully supplied in the form of plain boiled water, barley- 
water or weak tea. If the infant refuses to take water freely 
it may be sweetened by the addition of a grain of saccharine 
to the pint. The bowels should be thoroughly flushed with a 
high enema of normal salt solution and this may be repeated 
according to indications. 

On the second day lamb or chicken broth, cooked with rice 
or barley, strained and then cooled in order to remove the fat, 
may be given in quantities slightly less than the infant was 
taking before its illness and at four hour intervals, water being 
given between feedings. 

On the third day, if the fever has subsided and all curds have 
disappeared from the stools we may cautiously begin with a 
milk preparation, preferably "Eiweissmilch," or albumin milk. 
The beneficial action of this food in diarrhea is largely due to 
its high protein and calcium content, which favors the formation 
of soap stools in the intestine. Peristalsis is thereby checked 
and diarrhea overcome. The presence of buttermilk in this 
food may also exert a beneficial effect through the antagonistic 
action of the lactic acid bacilli to the gas bacillus and colon 
group. 

It is not always possible to employ "Eisweissmilch" because 
of the skill and care required in its preparation. As a routine 
measure I have found the use of dilute skimmed milk prep- 
arations highly practicable and generally successful. We should 
begin with one part skimmed milk to three parts barley-water, 
rice water or arrowroot-water, mixed and boiled for five 
minutes. 

The proportion of milk may be cautiously increased until 
two parts of milk to one of diluent is reached. With this food 
the stools usually become yellowish, salve-like and alkaline in 
reaction. When this result is attained one of the maltose 
preparations may be cautiously added to the food. We should 
also do this when feeding "Eiweissmilch," for without a suffi- 
11 



146 DISEASES OF CHILDREN 

cient amount of carbohydrate in the food the infant soon 
becomes seriously emaciated. A gradual return to whole milk 
should be made after the diarrhea and fever have been definitely 
controlled, but the milk should be boiled for at least several 
weeks after an attack of enteritis. 

In ileocolitis, or dysentery, Kendall recommends the use of 
lactose on account of its antagonistic action to the dysentery 
bacillus. Cases of ileocolitis are often starved entirely too long 
and thus unnecessarily weakened. We should remember that 
the lower bowel is involved in these cases and that properly 
modified milk and thin gruels are well digested before they 
reach the inflamed colon. 

In ileocolitis it is common to find several mucous stools in 
succession followed by a pasty milk stool. Albumin milk or 
boiled skim milk mixtures are usually well tolerated. 

Special Symptoms and Their Management. — Vomiting 
is at times a most troublesome complication, especially in 
cholera infantum. Lavage of the stomach is the most rational 
and successful method of treatment to control it. In urgent 
cases it may be necessary to perform the operation several times 
a day, and then pour a little food into the stomach before 
removing the tube. Thin arrowroot-water or albumin-water is 
best retained under these circumstances. Often the food will 
be retained better if fed with a teaspoon than when taken from 
a bottle. 

Diarrhea. — In the early stages of an intestinal infection 
irrigation of the bowel is beneficial. The gut seldom empties 
itself completely for which reason the diarrhea and toxic 
symptoms persist. It is true, the irrigating fluid does not reach 
beyond the ileo-cecal valve, but, as the colon receives the brunt 
of the attack in most instances, we help the case materially by 
cleansing this part of the gut. Besides, irrigation stimulates 
peristalsis, and thus aids in emptying the portion of gut above 
this point. 

Foul stools and excessive mucus call for irrigation, but we 



DISEASES OF THE GASTROINTESTINAL TEACT 147 

must discontinue as soon as the improvement sets in as a 
diarrhea may be prolonged by too much mechanical interference. 

Tenesmus may be relieved by injections of olive oil. 

High fever is best controlled with baths. Infants may be 
tubbed two or three times daily in water gradually reduced 
from 90° F. to 80° F., while older children are more con- 
veniently sponged with cool water and alcohol. Irrigation of 
the colon tends to control the pyrexia. The child should be 
kept in the open air as much as possible. 

Collapse calls for stimulation. Brandy should only be used 
when needed, and not given continually during the illness. 
In grave cases a hypodermic injection of camphorated oil may 
be necessary. Five minims may be given to an infant one 
year old. Camphor suits this condition admirably, and it is 
best given hypodermically, as it may otherwise irritate the 
stomach. Artificial heat should also be applied when the body 
surface becomes cold or the temperature subnormal. When 
the infant has been rapidly depleted by frequent watery stools 
hypodermoclysis may be resorted to. From fifty to one hundred 
cubic centimetres of normal salt solution may be injected 
subcutaneously with a large sized Luer Syringe. The intra- 
peritoneal administration of normal salt solution is more 
effective than the subcutaneous method and is perfectly safe 
when properly performed. In cases of acidosis Howland recom- 
mends fifty cubic centimetres of a four per cent solution of 
sodium bicarbonate subcutaneously or intravenously. 

Remedies. — The diarrhea accompanying teething is espec- 
ially benefited by chamomilla. In acute gastro-intestinal 
intoxication belladonna appears most frequently indicated on 
account of the predominance of fever and nervous symptoms. 
Even in the later stages, when the bowel symptoms become more 
prominent, belladonna is of value as long as fever and toxemia 
are present. 

In the ordinary case of fermental diarrhea and ileocolitis 
podophyllum 3 x is a good routine remedy. Mercumus 



148 DISEASES OF CHILDREN 

vivus 3 x trit. may be given later, if ulceration takes place. 
This is indicated by the continuance of the diarrhea, moderate 
fever and a persistence of mucus in the stools. In the dys- 
enteric type of colitis, mercurius corrosivus 6 x is the 
chief remedy. 

Arsenicum, ipecac and veratrum album are the most useful 
remedies in cholera infantum. Veratrum is Jousset's favorite. 
Iris versicolor will check the vomiting speedily, but leaves the 
bowels untouched according to Kichard Hughes. Arsenic and 
veratrum are often difficult to differentiate, especially in the 
beginning of the case. Under these circumstances they may be 
given in alternation. I have often found that when one of the 
apparently indicated remedies fails to act, prompt improvement 
will follow on giving a constitutional remedy in alternation with 
the same. Among these calc. phos. stands foremost. 

Aeon. — In the beginning; high fever and restlessness; green 
mucus in the stools. 

Apis. — Cerebral symptoms ; suppression of urine ; coma, with 
hot head, dry skin ; shrill cry ; hydrocephaloid state. 

Arsen. — Watery stools, with vomiting and collapse; stools 
offensive, first greenish, later becoming dark or brownish, and 
acrid; also small mucous stools with tenesmus. Child nurses 
often, but takes only a small quantity at one time. Mainly 
differentiated from veratrum album by presence of greater 
prostration and toxemia. 

Bell. — Green stools, abdomen distended and sensitive ; face 
red, high fever. Where inflammatory symptoms are pronounced 
belladonna is the most important remedy especially when brain 
symptoms develop. 

Bry. — Diarrhea brought on by change of weather; stools 
brownish, worse from moving about; great thirst for large 
quantities of water. 

Calc. carb. — Stools light in color, sour odor ; sour vomiting ; 
dentition ; rachitic tendency ; belly large. 

Calc. phos. — Child looks old, under-developed ; stools greenish, 



DISEASES OF THE GASTROINTESTINAL TRACT 149 

thin and offensive; history of tardy dentition; belly flabby. 
A most valuable tonic both during the disease and in con- 
valescence. 

Camphor. — Sudden appearance of choleraic symptoms ; great 
prostration and collapse, body cold yet child will not re- 
main covered. 

Cham. — Stools green, with white particles, looking like 
"spinach and chopped eggs;" fretful; one cheek red, the other 
pale ; child wants to be carried about. 

Colocynth. — Painful cases; pressure gives relief. 

Croton tiglium is of clinical value in gastroenteric infections 
where the stools are profuse and watery and of a yellow color. 
The mother will tell you that every time the child takes the 
bottle it has a bowel movement, drinking apparently exciting 
peristalsis and bringing on a stool. It is distinguished from 
podophyllum by a less amount of gas and mucus and absence 
of straining. 

Cupr. ars. — Painful cases; choleraic and convulsive symp- 
toms predominate. 

Ipecac. — Nausea and vomiting; stools green as grass, or like 
yeast. Early stages of cholera infantum. 

Mag. sulph. — Dr. Frank H. Pritchard (Hahnemannian 
Monthly, Nov., 1900) reports favorable results from the use of 
a weak solution of the Sulphate of Magnesia in the summer 
diarrhea of children. His dosage is one-half to one grain 
dissolved in a teaspoonful of water. The indications calling 
for it are copious, watery stools, deficient in bile. He noted that 
as soon as the remedy had begun to act favorably the stools 
became bile-tinged. 

Mercurius. — A predominance of mucus and involvement of 
the lower colon calls for mercury. The bichloride is often 
preferable to the metal in dysentery; mercurius dulcis has 
grass-green stools. The "never-get-done" feeling of mercurius 
sol. is very characteristic, while the bichloride has tenesmus 
of the bladder as well as of the rectum, and is the chief remedy 
in true dysentery. 



150 DISEASES OF CHILDREN 

Podophyllum. — Painless, yellowish or greenish, watery dia- 
rrhea; prolapsus ani. The stool is expelled with a spluttering 
sound due to the presence of gas in the bowels. The buttox 
becomes excoriated. Podophyllum is the best routine remedy 
in acute enteritis. 

Sulphur. — Excoriating stools, worse mornings ; marantic 
cases. The child is peevish and has a voracious appetite. The 
lips are abnormally red and the anus is excoriated. Exudative 
diathesis; eczema. 

Veratr. alb. — Vomiting and purging, the latter most prom- 
inent; motion aggravates all symptoms, cold sweat on forehead. 
There is less prostration and thirst than with arsenicum, less 
restlessness and usually more pain, and when any doubt exists 
as to a choice between the two, veratrum should receive the 
preference early in the case. Arsenicum is indicated in the later 
stages when exhaustion and prostration have become the 

prominent symptoms. 

CONSTIPATION. 

Constipation is one of the commonest and most troublesome 
conditions encountered in infancy. As a rule it is of no serious 
import, being mainly dietetic in origin. It may, however, result 
from atony of the intestines and abdominal walls and is, there- 
fore, frequently associated with rickets. In some instances 
there is an anatomic basis; this may be an elongated sigmoid, 
prolapse of the colon or congenital dilatation and hypertrophy 
of the colon (Hirschsprung's disease). Eissure of the anus, 
by causing a reflex spasm of the sphincter ani, may also be a 
cause of stubborn constipation. 

A normal nursing infant usually has from three to four 
bowel movements daily, while an artificially fed infant gen- 
erally has but one or two. In the former instance the stools are 
thin and contain small, soft curds of fat, although they are at 
times pasty, while in the artificially fed infant the stool is of 
firmer consistency and more homogeneous. After the infant is 
weaned and other foods than milk are added to the diet there is 



DISEASES OF THE GASTROINTESTINAL TEACT 151 

usually one bowel movement daily, approaching the type of 
stool seen in adults. 

In the majority of instances some dietetic error will be found 
responsible for the condition, although it should not be forgotten 
that infants are naturally predisposed to constipation on account 
of the relatively great length of the intestinal tract and the 
exaggerated curve of the sigmoid flexure. The musculature of 
the intestines is relatively feeble, and for this reason long 
continued impaction of the gut with fecal residue and over- 
distention from fermentative processes may lead to permanent 
dilatation of the colon. It is a mistake to believe that fecal 
impaction is uncommon in young children, and whenever ab- 
dominal symptoms are encountered this is one of the first 
conditions to be looked for. 

Again, habit must also be taken into consideration, for it 
plays a prominent role in the etiology of constipation in children 
as well as in adults. A great many cases are the direct result of 
bad training; it is surprising how early some infants can be 
taught to have regular bowel movements. 

An important point to bear in mind is that the infant may 
appear to be constipated when in reality it is not getting 
sufficient food or the same is so deficient in solids that there is 
not enough fecal residue in the intestinal tract to produce 
the usual number of evacuations. 

It is generally taught that deficiency in fat in the food is the 
chief cause of constipation in infants, and while this is true to 
a certain extent, nevertheless much harm has been done by the 
indiscriminate application of this principle. There is no doubt 
that the increase of fat in a milk formula beyond a certain 
percentage may not only aggravate the constipation, but may 
also induce a train of serious general symptoms resulting from 
disturbed metabolism and fat dyspepsia. An increase in carbo- 
hydrates is more important that an increase in the fat, excepting 
in cases which have been on a diet with distinctly low fat per- 
centage. It is well to remember that the percentage of fat in 



152 DISEASES OF CHILDREN 

a formula should never be increased beyond 4 per cent, and that, 
as a rule, 3 per cent of fat is sufficient for the infant's 
requirements. 

The substitution of maltose for lactose in the food will also 
act beneficially in many instances in relieving constipation. 
Oatmeal water, used as a diluent for the milk, exerts a laxative 
effect. A drink of sugar water between feedings will often 
give good results. 

In the case of older children we have more latitude in the 
regulation of the diet. Fruit and a glass of water before 
breakfast should be insisted upon. The amount of meat should 
be restricted, and the eating of cereals, vegetables and fruits 
either raw or stewed, should be urged. Graham bread should 
be substituted for wheat bread. Agar may be given with a 
cereal and is more efficacious than bran. A useful adjuvant in 
the treatment of these cases is a dessert-spoonful of olive oil 
mixed with an ounce of unfermented grape juice taken twice 
daily, one hour after meals. 

Local conditions, such as fissures of the anus and polypi, must 
be looked for. The systematic use of enemata is of decided 
value in habitual constipation, and their employment is es- 
pecially indicated when the stools are large and hard. A gluten 
suppository may also prove valuable in establishing the habit 
of evacuating the bowels at a regular time each day. 

Massage is of value in infants to stimulate peristalsis and 
assist in the dislodgment of fecal accumulations. 

The remedies most frequently useful are bryonia, Hydrastis, 
nux vomica and sulphur. Other remedies which may be called 
for upon special indications are alumina, calc. carb., graphites, 
lycopodium, mercurius vivus, opium, phosphorus. If it 
becomes necessary to resort to physiological measures we should 
avoid the use of drugs which are either harmful or which only 
aggravate the condition. 

Castor oil should only be used in acute conditions in which 
a rapid emptying of the bowels is imperative. 



DISEASES OF THE GASTROINTESTINAL TRACT 153 

Hydrated magnesia, which is marketed as "milk of mag- 
nesia/' may he added to the milk in place of lime water, and 
thus serve the double purpose of an alkali and mild laxative. 
One drachm added to the twenty-four hours' amount of food 
will usually he found sufficient. Older children may take a 
teaspoonful in water at bedtime. 

The general and indiscriminate use of the popular syrups 
(proprietary) which contain senna and Rochelle salts, is to be 
discouraged, although senna is the least harmful of the 
various laxatives. 

Ox-gall is a cholagogue, and may be given in one grain doses 
in cases characterized by deficient biliary secretion. 

Bryonia. — Stools large and dry, as if burnt. 

Graphites. — Stool consists of small balls bound together by 
mucus. Fissure ani ; eczema ani ; fat babies with skin eruptions. 

Hydrastis. — Constipation due to atonic dyspepsia and portal 
congestion; mucous colitis; catarrhal affections in general; loss 
of appetite. " Constipation after purgative medicines" 
— (Goodno). 

Nux vomica. — The child strains and grunts but passes little 
or no stool ; the abdomen is distended and hernia is apt to result 
from the constant straining. 

Sulphur. — Habitual constipation with general malnutrition; 
anus sore after stool ; prolapsus ani and hemorrhoids ; alternate 
constipation and diarrhea. 

INTUSSUSCEPTION. 

Intussusception is most frequently seen in infancy, and has 
been found to occur oftener in boys than in girls. It is 
probably due to increased peristalsis and occurs, as a rule, in 
poorly nourished infants during an acute intestinal disturbance. 

The condition is one of invagination of one portion of the 
intestine into another, most frequently the lower end of the 
ileum, together with the cecum being invaginated into the colon. 
The invaginated portion produces a sausage-shaped tumor in 



154 DISEASES OF CHILDREN 

the region of the cecum or transverse colon, often advancing 
over into the left lower quadrant of the abdomen. It may at 
times be felt in the rectum, even protruding therefrom. 

The onset is usually sudden, the symptoms being colicky 
pains, with vomiting and straining at stool. The lower bowel 
soon becomes emptied of its fecal contents, after which passages 
of blood and mucus make their appearance. The vomiting 
becomes stercoraceous unless the obstruction is relieved, and 
the patient dies in collapse. 

'Spontaneous reduction or sloughing of the invaginated por- 
tion of the gut, and successful union with restoration of the 
lumen of the canal may occur in exceptional instances. 

The prognosis is grave unless the intussusception can be 
reduced within a reasonable time of its occurrence. Gibson 
(N. Y. Medical Record, July 17, 1897) estimates the mortality 
as 53 per cent from a collection of 249 cases. Early operation 
is indicated. 

Diagnosis. — The majority of cases of intestinal obstruction 
occurring in infancy are due to intussusception. Symptoms of 
obstruction, therefore together with the presence of the sausage 
shaped tumor in the abdominal cavity and in the rectum, bloody 
stools and active movements of the intestinal coils above the seat 
of obstruction and projectile vomiting and collapse are the 
symptoms upon which the diagnosis should readily be made. 

APPENDICITIS. 

Appendicitis is seldom seen as early as intussusception, only 
exceptionally occuring during infancy, and rarely before the 
fourth year. The causes are the same as in adults. Appendic- 
ular colic is more common in children, however, than in adults, 
owing to the more patulous state of the opening of the appendix 
into the cecum, permitting the entrance of fecal concretions 
(stercoraceous appendicitis) . 

The catarrhal variety is characterized by its mild course and 
absence of complications. It is usually of the chronic recurring 
variety. 



DISEASES OF THE GASTROINTESTINAL TRACT 155 

The perforative variety is accompanied by fever, pain, local 
tenderness and rigidity and a leukocytosis. Unless prompt 
surgical treatment is instituted there is always the danger of 
perforation and septic peritonitis occurring. 

The clinical features of appendicitis are very characteristic, 
and are tersely and clearly described by Van Lennep ("Appen- 
dicitis," Tra?is. of the American Institute of Horn., 1897) : 

"There is the history of improper eating, or perhaps exposure 
to cold, associated with the menstrual period in the female; 
occasionally over-exertion, particularly in the sedentary, or 
possibly a direct traumatism. Then, what have been aptly 
termed the cardinal symptoms: (1) Pain, at first peri-um- 
bilical or diffuse, but soon referred to the right iliac fossa, 
unless the appendix points elsewhere. (2) Tenderness, almost 
always present at the junction of the organ with the cecum 
(McBurney's Point) ; sometimes associated with other sore 
spots corresponding with distal lesions or their products. (3) 
Muscular rigidity, to corroborate tenderness, which may vary 
from a local or general board-like stiffness to an indistinct, 
circumscribed muscular tension, or a barely appreciable differ- 
ence between the two recti at their costal margin. Besides this 
three-legged stool, as Hering would have termed these cardinal 
symptoms, are the well known concomitants : Sudden onset, the 
coated, flabby and indented tongue ; the vomiting, which, when 
present, is from an overloaded or rebellious stomach; constipa- 
tion, sometimes preceded by an irritative diarrhea; distention, 
usually local in the early 'tympanitic tumor,' due to atony of 
the cecum from an irritated appendix; and, lastly, as might be 
expected, a moderate temperature rise and pulse acceleration." 

Diagnosis. — With the presence of the above symptoms the 
diagnosis of appendicitis is not difficult. From intussusception 
it is differentiated by the absence of projectile or stercoraceous 
vomiting, bloody stools and intestinal tumor. Furthermore, in 
intussusception there are active movements of the intestines, 
while in appendicitis "actively-moving intestinal coils are not 



156 DISEASES OF CHILDREN 

seen or felt and gurgling is scanty or absent" (Van Lennep). 
Eeferred pain in the right iliac fossa is not uncommon in 
pneumonia of the right base in childhood, due to an associated 
pleurisy. A routine examination of the chest should, therefore, 
be made in all cases of suspected appendicitis in children. 

Treatment. — The majority of cases of intussusception and 
appendicitis are first seen by the general practitioner. It is 
his duty, therefore, to be thoroughly familiar with the symptoms 
and diagnostic signs of these conditions so that he may be able 
to recognize them and make an early diagnosis. If the surgeon 
is called in too late, no matter how skillful he may be, he can no 
longer do justice to either himself or to the patient. The 
responsibility, therefore rests mainly with the family physician 
who is the first to see the case. 

In regard to surgical treatment Van Lennep says: "My 
working-plan regarding operation is about as follows: In a 
severe attack, characterized by sudden onset, and particularly 
by intense cardinal symptoms, with or without corresponding 
concomitants, operation should be undertaken at once. In a 
milder seizure, the more common form, recovery may be looked 
for, with the hope of an interval operation. In deciding the 
question of persistence in such cases I have come to rely more 
than ever on the twenty-four hour limit, and I believe that 
whenever doubt or would-be conservatism has induced me to 
delay, I have had cause to regret the inaction. Benign cases 
will show signs of improvement within twenty-four hours, while 
unfavorable cases, requiring operation, usually grow worse 
during this time, and become dangerous from the possibility of 
perforation with septic infection of the peritoneal cavity." 

It is best to discontinue all feeding by mouth and resort to 
enteroclysis, after a preliminary enema. An ice bag placed 
over the region of the appendix adds to the patient's comfort. 
Morphine should not be used as it masks the symptoms of the 
case. One of the following remedies may be indicated: 

Nux vomica. — This is the most important remedy in the early 



DISEASES OF THE GASTROINTESTINAL TRACT 157 

stage, indicated by coated tongue, nausea and vomiting, colicky 
pains in abdomen, constipation with urging to stool, abdomen 
tender and bloated. 

Belladonna. — Intense pain and sensitiveness in the right 
ileo-cecal region, cannot bear the weight of the bedclothes or 
to be touched. There is high fever, flushed face, vomiting, 
patient lying motionless on back with right leg drawn up. 

Bryonia. — Inflammatory stage. Bryonia covers the patho- 
logical condition more closely than any other remedy, and its 
cardinal symptom, pain aggravated by motion, together with 
inflammatory fever, thirst and constipation, are almost invari- 
ably present. 

Hepar sulph. — When suppuration has set in. 

Mercurius sol. — Painful tumefaction in right ileo-cecal re- 
gion; tongue broad and flabby, showing imprint ofi teeth; 
constipation ; fever, worse during night, with sweat, which gives 
no relief. 

INTESTINAL PARASITES. 

The parasites which may be found infesting the intestinal 
tract of children are two round worms, the oxyuris vermicularis 
and ascaris lumbricoides, and two tape worms, tenia saginata 
and tenia solium. 

There are no characteristic symptoms upon which intestinal 
parasites can be positively diagnosed. In the case of the oxyuris, 
itching about the anus is commonly present and should arouse 
suspicion of the presence of seat worms. The symptoms 
attributed to the ascaris, or "stomach-worm" are, however, 
often produced by other conditions such as intestinal indigestion 
or they are of neurotic origin. A positive diagnosis of the 
presence of these parasites can therefore only be made by 
finding the parasite or its ova in the stools. Many children who 
have worms, present no symptoms while others who grit their 
teeth at night and have digestive disturbances or febrile attacks 
of intestinal origin show no evidence of worms in their stools. 

Symptoms. — The characteristic disturbances induced by the 



158 DISEASES OF CHILDREN 

oxyuris vermicular is, or seat worm, are pruritus ani at bedtime, 
recurring regularly each night, in some cases even pains in the 
rectum; enuresis, and in male children erections with conse- 
quent masturbation. The worms also migrate into the vagina 
in females, inducing leucorrhea and masturbation. They are 
found in the feces, and can be detected at night emerging from 
the anus. 

The ascaris lumbricoides should be suspected when there are 
attacks of colicky pains; intestinal catarrh with loose stools or 
mucus in the feces; nausea and vomiting not due to disordered 
stomach ; irregular appetite ; pale countenance with dark circles 
under the eyes ; dilated pupils ; itching of the nose ; gritting of 
the teeth; restless sleep with starting, and atypical febrile 
disturbances. All of these symptoms, however, may be induced 
by other conditions, and these should be excluded before a 
diagnosis of worms is made. 

Dr. La Fuente (Presse Medical) considers attacks of intes- 
tinal colic coming on suddenly, seizing the child usually at play, 
and confined to one part of the abdomen, and bilateral narrowing 
of the field of vision as pathognomonic signs of ascarides. During 
the attacks of colic the abdomen is quite sensitive to palpation 
at the seat of the pain. These symptoms can undoubtedly result 
from worms but we must be on our guard and not mistake an 
attack of appendicitis for one of worm colic. It should also 
be remembered that the round worm sometimes migrates into 
the appendix and thus sets up a genuine attack of appendicitis. 

Tape-worms are far less commonly encountered in children 
than the seat worm and round worm. They are usually unsus- 
pected until segments of the worms are passed, although tape- 
worms may produce marked anemia. In every case of severe 
anemia the stools should be examined for parasites. 

Morphology. — The oxyuris vermicular is, also known as the 
thread-worm and seat-worm, is a small, whitish, thread-like 
parasite attaining a length of 10 m.m. in the case of the female, 
and 4 m.m. in the male. The female has an acuminate tail, 



DISEASES OP THE GASTROINTESTINAL TRACT 159 

while the male is blunt. They infest the lower ileum and upper 
colon, often in great numbers. The females prefer the cecum 
and the colon, and, when mature and egg-bearing, migrate into 
the colon and rectum to deposit their eggs, whence they also 
creep out of the anus at night. The eggs are oval, flat on one 
side and rounded on the other, and exceedingly small. Before 
they can develop they must first enter the stomach of some host, 
and it is quite likely that a child often reinfects itself by 
swallowing the eggs from its own colony of parasites. 

Ascaris lumbricoides. — This is the common round worm, 
being cylindrical in shape, with tapering extremities and light 
reddish-brown in color. The female may attain a length of 
fifteen inches ; the male eight to ten inches. The eggs are larger 
than those of the oxyuris, and possess a double shell, the contents 
being dark and granular. They measure about %40 inch in 
length. The mature female sheds enormous numbers of these 
ova. The life history of the ascarides is not fully understood. 
They infest mainly the small intestines, although they may be 
found at any point in the alimentary tract, sometimes even being 
vomited, and in rare instances inducing death by creeping into 
the ductus communis choledochus or into the larynx. 

Tenia saginata. — This tape-worm is derived from beef, 
and is perhaps the most common variety in this country. It has 
a square head, with four suckers, but no hooks. It may attain 
a great length, and the segments are very numerous, and longer 
than broad. The life-history of the worm is as follows : After 
the eggs are discharged into the intestinal tract by the mature 
segments, they reach the alimentary tract of oxen grazing on 
pastures where the infected stools have been deposited. Here 
the embryos are liberated and find their way into the muscular 
tissue throughout the body, and sometimes into various organs, 
where they become converted into the cysticercus, or larval form. 
If this cysticercus is eaten with raw or insufficiently-cooked 
meat, the capsule is destroyed by the digestive juices and the 
contained scolex liberated, which attaches itself to the mucous 



160 DISEASES OF CHILDREN 

membrane of the small intestine, where it soon develops into the 
fully-matured form by segmentation. 

Tenia solium, also known as the armed tape-worm, is 
derived from pork, and differs from t. saginata in being 
equipped with a set of hooks besides two pairs of suckers. This 
parasite is also much smaller than the other variety and is less 
frequently encountered in the United States. 

Treatment. — In the case of oxyurides the best results are 
obtained from the use of high enemata of salt water. These 
must be given every night for several nights in succession. 
The salt water irrigations may be discontinued for a time and 
olive oil injections into the rectum substituted, using from three 
to four ounces of oil and letting the child retain the same over 
night. Should these measures not bring relief, a purgative, 
followed by a high enema of infusion of quassia may be 
employed. 

Ascarides are best gotten rid of by the administration of 
santonin, half a grain after meals for three or four doses 
followed by a purgative. The ascarides are not killed by the 
santonin but driven into the large intestine whence they are 
readily expelled by a dose of castor oil or citrate of magnesia. 

For the expulsion of the tape-worm the oleoresin of male fern 
is the most reliable anthelminthic. Fifteen minims should be 
given after a fast of twelve hours and followed by a saline 
purgative. 



CHAPTER VIII. 

DISEASES OF THE PERITONEUM. 

ACUTE PERITONITIS. 

Acute peritonitis is rarely seen in childhood. During infancy 
it is encountered as a manifestation of the newborn (see "Dis- 
eases of the Newborn' ') while in older children it develops 
secondarily to such conditions as appendicitis, intussusception 
and empyema. Acute peritonitis may also complicate the acute 
infectious diseases. 

Symptoms. — The onset of peritonitis is characterized by the 
development of painful abdominal distention with rigidity and 
tenderness ; vomiting, usually of bile and an increase in the 
fever and rising leucocyte count. Since peritonitis is usually 
secondary to some other condition the advent of the above 
symptoms should at once arouse suspicion of a complicating 
peritonitis. 

As the condition progresses peristalsis is abolished; the 
respirations become shallow and the abdomen does not move 
with the respirations and the face assumes the "abdominal, or 
Hippocratic" expression. The eyes are hollow and sunken, the 
features become pinched, the face is cold, there is a distressed 
expression and the mind remains clear. The pulse is small and 
rapid and collapse is impending. The outcome is usually fatal 
in cases of septic peritonitis. 

Treatment. — All feeding by mouth should be discontinued 
and water should be given by enteroclysis. Hot fomentations 
may be used to relieve the pain. When vomiting becomes a 
troublesome symptom lavage should be resorted to. 

The remedies useful in the early stages are aeon., bell, and 
bry. In the latter stages apis, canth., mercurius corr. and 
rhus tox. are indicated.. 
12 



162 DISEASES OF CHILDREN 

Aeon. — Sudden onset with chill; hot, dry skin; rapid, 
hard pulse, with high fever, great restlessness and anxiety. 
Cutting and darting pains in howels or burning in the abdomen. 

A pis. — Exudation; burning, stinging pains; scanty urine; 
loud piercing shrieks and cerebral symptoms; pneumococcus 
peritonitis coexisting with meningitis. 

Arnica. — After traumatism, in early stages. 

Arsenicum. — Later stages, impending collapse. Great an- 
guish; clammy perspiration; the patient feels cold, and 
complains of burning pains in abdomen ; restless tossing, thirst, 
obstinate vomiting, distention of the abdomen and cold 
extremities. 

Camphor. — Collapse. 

Cantharis. — Intense inflammation, pinched features, rapid, 
feeble pulse, cutting and burning pains. (Goodno.) 

Carbo veg. — Great distention of the abdomen, with paralysis 
of the bowels. Extremities cold up to the knees; collapse. 

Lachesis. — Great hyperesthesia of the abdomen; compli- 
cating gangrenous inflammation of the appendix; loquacious, 
adynamic fever. 

Merc. — When the exudate tends to become purulent, indicated 
by chilliness, followed by sweat; starting in sleep; cachectic 
expression; foul breath; emaciation; obstinate vomiting. 

Opium. — Paralysis of bowels or antiperistaltic action; in- 
cessant vomiting, distention of abdomen, somnolence and stupe- 
faction; warm sweat. 

Rhus tox. — The rhus tox. patient prefers to lie on his back 
with the legs drawn up, although the pains make him very 
restless. There is delirium at night, great prostration, and a 
brown tongue with red tip. 

Sulphur. — To hasten resorption of exudate. 

CHRONIC PERITONITIS; TUBERCULOUS PERITONITIS. 

Chronic peritonitis is usually tuberculous. Fetal peritonitis 
may be of syphilitic origin. Tuberculous peritonitis is usually 



DISEASES OF THE PEEITONEUM 163 

secondary to intestinal tuberculosis, infection taking place from 
caseating mesenteric glands ; primarily it may develop as the 
acute miliary type or as a part of an acute miliary tuberculosis. 
Abdominal tuberculosis in children is usually due to the bovine 
type of tubercle bacillus. 

Symptoms. — The following clinical types of tuberculous 
peritonitis are encountered: 

The acute miliary type which presents the symptoms of acute 
peritonitis and is rapidly fatal. 

The ascitic type which may be idiopathic or tuberculous. 
It is accompanied by an exudate of serum, or a purulent fluid 
in case of mixed infection. 

In the adhesive type there is a matting together of the intes- 
tines by bands of plastic exudate. Caseous masses in the 
mesentery and in the organized exudate, and a firm mass 
containing coils of intestine, difficult to entangle after the 
abdomen has been opened, result from the tuberculous process. 
Obstruction of the bowel finally occurs. The fibro-plastic variety 
presents adhesions together with fibrinous exudation, which may 
undergo caseous degeneration and induce ulceration into neigh- 
boring organs. Fecal fistulas forming in the neighborhood of 
the umbilicus are not uncommon in these cases. 

The symptoms of tuberculous peritonitis are progressive loss 
of weight with moderate fever ; anemia ; diarrhea which is either 
persistent or recurring and abdominal distention. The diarrhea 
usually precedes the development of peritonitis and is due to 
intestinal tuberculosis. 

The course is slow and may terminate in spontaneous re- 
covery, especially in the fibro-plastic type, although death 
usually results from extensive adhesions of the abdominal 
viscera. The ascitic form frequently recovers under surgical 
treatment, but relapses and general infection are always to 
be feared. 

Diagnosis. — The presence of fluid in the abdominal cavity, 
together with evidence of a thickened omentum and nodular 



164 DISEASES OF CHILDREN 

masses in the region of the small intestines should suggest the 
diagnosis of tuberculous peritonitis especially if other evidences 
of tuberculosis are present. These latter are interscapular 
dulness, fever and emaciation and a positive von Pirquet test. 
A preceding chronic diarrhea should suggest intestinal tuber- 
culosis. The abdomen is uniformly distended and fluctuating 
and shifting dulness in the flanks can be elicited in ascites 
without adhesions. Ridges and irregular contour of the abdo- 
men suggest adhesions while stationary dulness speaks for 
sacculated fluid. In the adhesive variety an irregular tumor 
can usually be palpated. Chronic obstruction of the bowels 
gradually develops when the adhesions constrict the gut. 

In the presence of marked ascites, hepatic disease must be 
excluded before a diagnosis of peritonitis can be made with 
certainty. In peritonitis the fluid contains more albumin and 
is of a higher specific gravity than in peritoneal effusions of 
circulatory or renal origin. There is also a high mononuclear 
cell count. Cirrhosis of the liver does not occur in childhood 
but pseudo-cirrhosis accompanying adhesive pericarditis (poly- 
serositis) is not uncommon in children and must be excluded 
(see "Diseases of the Heart"). 

Treatment. — Owing to the favorable results obtained by 
laparotomy, every doubtful case should receive the benefit of 
an exploratory incision. The ascitic variety is the one especially 
benefited by laparotomy and evacuation of the fluid; in the 
others it is of doubtful value. Sutherland (Archives of Pedi- 
atrics, Feb., 1903) is not in favor of surgical intervention since 
in forty-one cases observed by him the results of medical treat- 
ment of all varieties were much better (70 per cent recovered) 
than of surgical treatment (50 per cent recovered, 50 per cent 
died). The usual regime of diet and fresh air should be carried 
out. Tuberculin in minute doses, either internally or subcu- 
taneously should be tried. Other remedies to be considered are 
iodine, the iodide of arsenic and calcerea carb. 



CHAPTER IX. 

DISEASES OP THE RESPIRATORY TRACT. 

SPASM OF THE GLOTTIS. 

Spasm of the glottis, or laryngismus stridulus, is one of the 
chief clinical manifestations of the spasmophilic diathesis. It 
should not be confounded with the respiratory difficulty result- 
ing from an enlarged thymus gland, the so-called thymic asthma 
of Kopp, which is a symptom of the lymphatic diathesis, or 
status lymphaticus. 

Laryngismus stridulus is most frequently encountered during 
the first year ; it is rare in older children and more common in 
boys than in girls. Symptoms of rickets are usually associated. 

An attack is usually brought on by crying or by fright. 
Sometimes it comes on without any apparent cause. The child 
suddenly holds its breath and then makes ineffectual efforts to 
inspire which is made impossible by the spasmodic contraction 
of the vocal cords. The features become cyanotic and temporary 
asphyxia results. This may last until partial unconsciousness 
and complete relaxation ensue, after which inspiratory efforts, 
accompanied by a crowing sound, are made. Consciousness 
returns, the crowing sounds disappear and the child is again 
normal. Death from cardiac failure may occur during one of 
these attacks {cardiac tetany). 

Congenital stridor of infants is a condition which should be 
mentioned in connection with glottic spasm. Its true nature is 
not fully understood. In some cases disturbed innervation of 
the laryngeal muscles is perhaps present while in other cases 
there is a congenital malformation of the glottis. 

Treatment. — Since laryngismus stridulus is only a symptom, 
treatment must be directed toward improving the underlying 
constitutional disturbance. The infant should therefore be 



166 DISEASES OF CHILDREN 

thoroughly examined for evidences of spasmophilia and rickets 
and treated accordingly. 

During an attack of laryngeal spasm the child should be 
sprinkled with cold water and the index finger introduced into 
the throat to raise up the epiglottis, as in performing intubation. 
A quick acting stimulant like camphor, given hypodermically 
may be required. Belladonna and magnesia phos. may be given 
to lessen the tendency to a return of the spasm. The diet and 
constitutional treatment is that of rickets. 

ACUTE CATARRHAL LARYNGITIS; SPASMODIC CROUP. 

This form of croup, which must be distinguished from true 
croup , or membranous croup (laryngeal diphtheria), is a com- 
mon affection of childhood, being a catarrhal inflammation of 
the mucous membrane of the larynx associated with spasm of 
the interior laryngeal muscles. 

The anatomical and physiological pecularities of the larynx 
and nervous system of young children, namely, the relative 
smallness of the larynx and rima glottidis, the great vascularity 
of its lining mucous membrane and the heightened reflex 
excitability of its nerve-supply, offer a ready explanation for 
the frequency of this malady during childhood and the spas- 
modic and paroxysmal character of the symptoms. 

Etiology. — The chief exciting causes are exposure to cold, 
draughts or wet weather ; acute indigestion and direct irritation, 
such as the inhalation of dust or contaminated atmosphere. 
Attacks occur more frequently during the winter and early 
spring than in the milder and dryer season. Male children are 
more frequently attacked than females, and the age at which it 
is most likely to occur is between the second and third year. 
The majority of children who are subject to croup are of a 
nervous temperament and have enlarged tonsils and adenoids. 

Symptoms. — The characteristic feature of spasmodic croup 
is its paroxysmal nature. The child may have been well during 
the day, but towards night a ringing metallic cough — sometimes 



DISEASES OF THE RESPIRATORY TRACT 167 

before retiring, at other times not until the child has been asleep 
— makes its appearance. Usually the child is aroused from 
sleep by an attack of cough and choking, as a result of which, 
it is much agitated and frightened. The breathing is oppressed, 
inspiration almost impossible, prolonged, and accompanied by 
a harsh rasping sound, while with expiration there is a ringing, 
metallic (croupy) cough. 

The attack may last from a few minutes to an hour or longer, 
not, however, in one continued degree of severity. A second 
milder attack is likely to occur during the same night, and on the 
following night it may be looked for with all probability. A 
moderate amount of fever, together with some catarrhal secre- 
tion is usually present. The condition rarely results fatally. 

A more severe form of acute laryngitis is at times encoun- 
tered, simulating membranous croup. In these cases there is 
more fever and more severe inflammation of the throat and 
cultures for the diphtheria bacillus are negative. 

Spasmodic croup is differentiated from membranous croup 
by the absence of constitutional symptoms ; absence of dyspnea 
between the choking attacks ; absence of aphonia and of exudate 
on the tonsils and in the larynx. Membranous croup becomes 
progressively worse while catarrhal croup is paroxysmal, worse 
at night and recurring in nature. 

Treatment. — During an attack of croup the inhalation of 
steam from a croup-kettle helps to relieve the cough and difficult 
breathing. The rooms should be kept warm and warm drinks 
may be given. A warm pack about the throat will also prove 
beneficial. 

Many remedies have been recommended for croup and an 
emetic is sometimes given for the purpose of loosening the 
secretion and overcoming the laryngeal spasm. In my experi- 
ence, however, the effect obtained by the administration of 
ipecac is disappointing. Belladonna 2x and tartar emetic 3x 
trit. given every fifteen minutes alternately during the attack 
and every hour between attacks give the best results. To avoid 



168 DISEASES OF CHILDREN 

recurrences the child's general condition should be looked into 
and enlarged tonsils and adenoids removed. 

ACUTE BRONCHITIS. 

Acute catarrhal bronchitis is one of the commonest ailments 
of childhood. It may develop primarily or as an extension of 
an upper respiratory infection, or common "cold." The micro- 
organisms usually encountered in acute bronchitis are the pneu- 
mocoecus, the staphylococcus aureus and the streptococcus vir- 
idans. During epidemics of influenza the influenza bacillus is 
the predominating organism. Bronchitis also frequently devel- 
ops secondarily, being a frequent accompaniment of most acute 
infectious diseases. 

Lack of fresh air and sunshine, overdressing, sleeping in a 
warm bedroom or living in crowded unhygienic quarters are 
prominent predisposing causes. Anemia and malnutrition also 
act as predisposing causes. During infancy rickets is an 
important predisposing cause; in older children adenoids play 
an important role. Some children exhibit a constitutional 
predisposition which may be hereditary. 

Several varieties of acute bronchitis are to be recognized. 
The mildest form presents an acute catarrhal tracheo-bronchitis, 
afebrile in its course and unaccompanied by constitutional 
disturbances. Babinsky prefers to call it bronchial catarrh in 
contradistinction to actual bronchitis. It is very prevalent 
among infants during the colder months of the year, and seems 
to be dependent upon atmospheric changes and constitutional 
predisposition. 

Acute febrile bronchitis is infectious in origin, is accompanied 
by constitutional symptoms, and tends to spread to the finer 
ramifications of the bronchial tubes and in early infancy may 
thus result in capillary bronchitis. When the process invades 
the pulmonary parenchyma, a true bronchopneumonia results. 

Pseudo-membranous bronchitis, or fibrinous bronchitis, is due 
to the extension of a diphtheritic infection from the larynx into 



DISEASES OF THE RESPIRATORY TRACT 169 

the bronchi. A chronic form of obscure origin is occasionally 
encountered. 

Pathology. — As in the case of spasmodic croup, a catarrhal 
inflammation of the bronchial tubes during infancy is of more 
serious import and accompanied by more suffocative symptoms 
than a similar condition in adult life. The greater vascularity 
of the mucous membrane, and the relatively smaller size of the 
tubes and air-vesicles are responsible for the development of the 
serious symptoms which may be noted in bronchitis in infancy. 
In fatal cases the mucous membrane appears swollen, injected, 
ecchymosed, and covered with mucus and purulent secretion. 
In the larger tubes the lining membrane alone is affected, while 
the smaller and finer ones are involved throughout their entire 
thickness in the inflammatory process. The lungs are usually 
emphysematous, from dilatation of the air-vesicles and blocking 
of the capillary tubes with secretion. Areas of atelectasis are 
also encountered. Dilatation of the bronchi may also result. 

Symptoms. — Bronchitis may run a mild or a dangerous 
course. In the first instance there is slight fever, cough, which 
at first is dry and irritating in character, later becoming loose 
and accompanied by rattling of mucus in the larger tubes. 
Some soreness in the region of the bifurcation of the trachea 
may be present, but the child evinces no great degree of pain or 
discomfort, and within a week or less the attack is over. 

When the smaller tubes, however, become involved, the case 
presents an entirely different aspect. There is rapid breathing, 
marked dyspnea, imperfect aeration of the blood and enfeebled 
circulation, higher fever (103° to 104° F. or over), and auscul- 
tation of the chest reveals the presence of sibilant rales and 
fine, moist rales in the bronchi. The child becomes exhausted 
from incessant coughing and being unable to expectorate the 
mucus which accumulates in the bronchi, it shows evidence of 
a gradually increasing asphyxia. It becomes dull and apathetic, 
even comatose, the pulse rapid and thready or imperceptible, 
and death, sometimes preceded by convulsions, terminates 
the scene. 



170 DISEASES OF CHILDREN 

This severe type, described as capillary bronchitis, is, 
strictly speaking, a bronchopneumonic process, and it is impos- 
sible to draw a sharp line between an acute spreading bronchitis 
and pneumonia. As stated above, the pulmonary parenchyma 
soon shares in the inflammatory process thus accounting for the 
serious symptoms observed. 

Diagnosis. — In bronchitis the percussion-note is not altered. 
In mild cases there are at first dry rales, followed by large, 
moist rales, with here and there a sibilant rale, all best heard 
posteriorly. In the second variety sub crepitant and sibilant 
rales, general in distribution, with large moist and dry rales in 
the large tubes and trachea, and areas of dullness, with dimin- 
ished respiratory murmur, indicating collapse of air-cells, may 
be elicited. Hyper-resonance, resulting from vicarious emphy- 
sema, is difficult to recognize in children, as the normal percus- 
sion-note is in itself highly resonant. 

Sufficient dilatation of some of the bronchi (bronchiectasis) 
to produce physical signs may result. In such cases bronchial 
breathing may be heard over the dilated bronchus and a tym- 
panitic note can be elicited by percussion. The sputum is 
purulent and separates into a purulent sediment superimposed 
by a fluid and frothy layer. 

Treatment. — In mild cases of bronchitis it is often advisable 
to keep the child out of doors as much as possible, instead of 
confining it to the house. The predisposition to bronchitis may 
be overcome by cold sponging, an out of door life and the 
correction of any local or general disturbances which may act 
as predisposing causes. 

Severe cases of bronchitis should receive all the care and 
attention accorded a case of pneumonia. 

The most frequently indicated remedies are aconite, bella- 
donna, bryonia, ferrum phos., hepar sulph., ipecac, mercurius, 
Pulsatilla and tartar emetic. These remedies must be 
differentiated according to their characteristic symptoms as 
given below. 



DISEASES OF THE EESPIEATOEY TEACT 171 

Aconite, belladonna, bryonia, ferrum phos. and mercurius 
are indicated in the early stages of the disease while hepar, 
Pulsatilla and tartar emetic are indicated in the later stages. 

Aconite has high fever, dry skin, absence of chilly feelings 
as in mercurius, absence of burning heat of the skin, as in 
belladonna, which has a dry, distressing, paroxysmal cough, 
usually worse towards evening. Belladonna is looked upon by 
some as a specific, it is not necessary, however, to administer it 
in physiological doses. 

The greatest usefulness for bryonia is to loosen the cough 
when the same remains hard, painful and non-productive and 
is accompanied by soreness of the abdominal muscles. The 
child is very thirsty, irritable and does not want to be moved. 
scilla is indicated by painful cough; it is, however, a more 
severe type than bryonia, there being cyanosis and failing 
circulation, owing to extension of the process into the finer tubes. 

Cham, suits mild cases of tracheo-bronchitis in the early 
stages ; the cough is excited by attempting to use the voice, and 
the child is fretful and cross. 

Ferrum phos. — Often preferable to aconite in cases charac- 
terized by hoarseness and dyspnea from the beginning, with 
rapid progress, soon assuming the capillary variety. The cough 
is short and dry, often paroxysmal, and when expectoration 
appears it is streaked with bright blood. 

Mercurius. — "Mercurius corresponds with the whole course 
of a severe attack of bronchitis, even better than belladonna. 
There is violent fever, the temperature is very high, there is a 
great disposition to sweat without obtaining any relief from it ; 
in contradistinction to belladonna there is a constant alternation 
of chills and heat, with a remarkable sensitiveness to the most 
trifling changes of temperature" (Baehr, Science of Thera- 
peutics). Tongue thickly coated yellow; diarrhea; cough 
dry, worse evening until midnight; dyspnea; expectoration 
tenacious. 

As the cough becomes loose, hepar sulph., ipecac, Pulsatilla 
and tartar emetic should be differentiated. 



172 DISEASES OE CHILDREN 

CHRONIC BRONCHITIS. 

Chronic bronchitis is less common in children than in adults 
as the reparative processes are more active during childhood 
and there is less tendency for an acute process, even when there 
are frequent recurrences, to become chronic. Bronchitis may 
persist for a long time after an attack of whooping-cough or 
measles. It may be secondary to Bright' s disease or organic 
heart disease or be a manifestation of tuberculosis. 

The important pathological changes are thickening of the 
mucous membrane, with areas of superficial ulceration, weak- 
ening and irregular dilatation of the bronchial tubes, and more 
or less extensive emphysema. 

The important symptoms are cough and expectoration, and, 
notwithstanding the long continuance of these symptoms, the 
general health rarely suffers to a marked degree. Naturally, 
these children are not up to the normal standard of health, as 
the etiology of the affection indicates ; however, there is not the 
gradual loss of weight and strength observed in a tuberculous 
condition. Children with chronic bronchitis usually also have 
asthmatic manifestations. 

The cough is loose, usually paroxysmal, and may become dry 
and teasing at times. It is generally worse in the morning, and 
the expectoration of large quantities of offensive muco-pus on 
rising, associated with localized coarse, moist rales, is strongly 
indicative of bronchiectasis. 

The course is a slow one and cases may be apparently cured 
in the summer only to have a relapse during the winter. Never- 
theless, the prognosis is favorable as a rule, provided that the 
child can receive the proper hygienic and medical care. 

Treatment. — An equable, moderately warm and dry climate 
is desirable; the mountainous pine regions are especially bene- 
ficial. Tonic treatment must be instituted in all cases — baths, 
fresh air, exercise and a highly-nutritious diet being the 
essentials. 



DISEASES OF THE RESPIRATORY TRACT 173 

The mouth, nose and throat must be carefully inspected for 
evidences of focal infection. Septal deflections, spurs and polpi 
are frequent sources of irritation but more commonly adenoids 
and enlarged tonsils will be found. Enlargement of the lingual 
tonsil is often responsible for persistent winter coughs and 
should be looked for. 

Hepar sulph. — I have found this remedy of especial benefit 
for the paroxysmal cough coming on at night. A powder of the 
third decimal trituration will usually relieve the attacks with 
astonishing promptness. 

Pulsatilla is indispensable for the loose cough with profuse 
easy expectoration of yellowish or yellowish-green muco-pus, 
having a tendency to become tighter and more troublesome 
at night. This remedy acts very satisfactorily with hepar, and 
I frequently employ it during the day, giving a dose of hepar 
at night. 

Lycopodium is particularly useful for the recurrent type of 
bronchitis, in which the patient is seldom free from a trouble- 
some cough, hatching cold" on the slightest provocation. 
"Cough dry, day and night, in feeble, emaciated boys." — (0. 
Wesselhoeft). Lithemic subjects; acid dyspepsia; cough 
ending with a loud belch. 

Sulphur. — This remedy presents many of the symptoms 
which are likely to be encountered in a case of chronic bronchitis. 
It is especially applicable to the cough associated with an 
unresolved pneumonia. It has not proven of much use where 
emphysema is present, but where there is a large amount of 
tenacious mucus, mixed with lumps of pus, of foul taste and 
odor, it seems particularly applicable. There may also be 
attacks of oppression of breathing, in which the patient gasps 
for air. 

Tart, emetic. — Useful in recent cases, with loud rales in the 
larger tubes, and dyspnea with the cough. 

The calcereas are especially called for upon their diathetic 
indications. 



174 DISEASES OF CHILDREN 

Calc. carb., besides its characteristic sweat, large belly and 
glandular enlargements, will be indicated by loose cough, with 
expectoration of yellowish, sweetish mucus, or dry, teasing 
cough, with dyspnea and palpitation of the heart from slightest 
exertion. Calc. phos. is more suited to the purely rachitic 
case with diarrhea, or cases of simple malnutrition. 

Silicea. — Emaciated children, tuberculous diathesis; night- 
sweats; profuse purulent expectoration; skin dry and scurfy; 
hectic fever; bronchiectasis; lack of normal body-heat, with 
constant chilliness. The cough is aggravated from cold drinks, 
and is deep and distressing. 

Besides these it may be necessary to resort to one of the 
following remedies for special conditions and symptoms: 

Ars. — Emphysema ; dyspnea. 

Carbo veg. — Hoarseness ; chronic spasmodic cough remaining 
after whooping-cough. General loss of vascular tone of the 
entire mucous membrane of the respiratory tract. 

Iodium.— Especially indicated in dark-complexioned, emac- 
iated children. Ravenous appetite without a corresponding gain 
in weight; enlarged bronchial glands. The iodides, especially 
the iodide of arsenic, are useful in the bronchitis and accom- 
panying wasting. 

Kali bichromicum. — Tough, stringy expectoration; cough 
excited by eating. Bronchitis after measles. 

BRONCHIAL ASTHMA. 
True bronchial asthma is a manifestation of anaphylaxis to 
a foreign protein. The child has become sensitized to some 
protein, usually one of the food proteins such as casein, egg 
albumin, wheat, oats, potato, etc. The absorption of these 
proteins from the alimentary tract causes irritation of the 
constrictor fibres of the vagus which results in spasm of the 
circular muscles of the small bronchi. The asthmatic attack 
with its accompanying dyspnea and cough is thus explained. 
A foreign protein may also act peripherally by coming in 



DISEASES OF THE RESPIRATORY TRACT 175 

contact with the mucous membrane of the upper respiratory 
tract as in the cases of asthma accompanying hay fever or 
following exposure to horses, cats, flour, etc. 

Asthma in children is usually associated with colds or bron- 
chitis, even when the condition is one of anaphylaxis. The 
mucous membrane in childhood is more sensitive than in adults 
and reacts to a foreign protein very much the same as to a 
bacterial infection. 

Walker (Medical Clinics of N. Amer., Jan., 1918) has found 
that sensitization to animal and bacterial proteins occurs in the 
following order of frequency: horse dandruff, staphylococcus 
aureus, wheat and other cereals, the pollens, cat hair, egg, milk. 
This includes cases of all ages. Cases beginning in early life 
usually show signs of sensitiveness to some food protein; those 
occurring later may be due to bacterial sensitization or some 
non-food protein. Asthma developing after the age of forty is 
usually due to chronic bronchitis or cardiorenal disease. 

Since the offending toxin may be of bacterial origin it is 
important to search for evidences of focal infection in the nose 
and throat and in the teeth in all cases. In Walker's experience 
the streptococcus hemolyticus is a frequent cause of the type 
associated with active bronchitis which he designates "asthmatic 
bronchitis." 

Symptoms. — The attacks occur suddenly, usually at night, 
the chief symptom being dyspnea, accompanied by a dry cough 
and characteristic respiration. The inspiration is difficult, 
accompanied by recession of the soft parts of the thorax, and 
expiration is prolonged. The respiratory murmur is dimin- 
ished, and the chest abounds in sibilant and sonorous rales; 
wheezing may be heard at quite a distance from the patient. 
Cyanosis becomes pronounced if the attack is a prolonged one. 
The attacks may last from a few minutes to an hour or more, 
and generally cease suddenly wifri a free secretion from the 
bronchial tubes; they recur at intervals of days or weeks. 

The catarrhal form or asthmatic bronchitis is the type in 



176 DISEASES OE CHILDREN 

which asthmatic manifestations gradually develop during at- 
tacks of bronchitis which are of recurring character. Whether 
these cases are bacterial in origin, due to protein sensitization 
or to some disturbance of metabolism, is a difficult problem to 
solve. There is no doubt that a constitutional predisposition to 
asthma, often hereditary, exists and asthmatic children usually 
show evidences of disturbed metabolism and a neurotic consti- 
tution. A marked eosinophilia is present in those cases which 
are distinctly anaphylactic in origin. In some cases this is 
lacking and abnormalities in the nose and throat will usually 
be found in this type of asthma. 

The diagnosis is readily made from the characteristic 
recurring paroxysmal attacks of dyspnea with prolonged 
wheezing expirations. Simple bronchitis, laryngismus stridulus 
and enlarged thymus must be excluded. The identification of 
the offending protein by means of the cutaneous test is often 
possible although the results are not as satisfactory in children 
as in adults. 

Treatment. — The same hygienic measures recommended for 
bronchitis are applicable to overcome the tendency to recurring 
attacks of asthma. All foci of local irritation in the nasopharynx 
or elsewhere should receive prompt attention. 

Every effort should be made to determine which particular 
kind of protein may be responsible and when found the same 
should be strictly eliminated from the diet. The gradual re- 
introduction of such a protein in small amounts into the child's 
diet will usually immunize the same against this food. 

In some cases it is necessary to burn stramonium leaves in 
order to make the suffering endurable. In severe cases a 
hypodermic injection of adrenalin chlorid may be necessary. 

Aeon, is recognized by its well-known mental condition, 
feverishness, etc. ; neurotic cases. 

Apis. — When the attacks seemingly follow the recession of 
an urticaria, or alternate with the same. The chest feels bruised, 
and the attack ends with the expectoration of a large amount of 
f rothv mucus and serum. 



DISEASES OF THE RESPIRATORY TEACT 177 

Ars. — Paroxysms between midnight and daybreak; must get 
out of bed ; great anguish and prostration ; bronchopneumonia. 

Ars. iod. — Between the attacks. It is a valuable remedy 
in cases of asthmatic bronchitis. 

Ipecac. — Wheezing; constant cough, with subcrepitant rales 
all over chest; no expectoration, although the chest seems full. 
Gagging and vomiting; the child stiffens during the choking 
attacks ; cyanosis and coldness of extremities. 

Lobelia. — In connection with disordered stomach; weakness 
in pit of stomach; attack preceded by prickling sensation in 
extremities; distressing tightness across upper portion of chest. 

Nux vom. — Asthma dyspepticum; attacks in morning; 
irritability and constipation. 

Pulsatilla. — Cough, becoming dry toward night, with dysp- 
nea ; inability to lie down ; chilliness ; mild, tearful disposition. 

An autogenous vaccine, made from the bronchial secretion of 
the patient, especially if the staphylococcus aureus or a strep- 
tococcus can be isolated and grown, offers the best prospects of 
curing cases which are associated with distinct evidences of 
bronchitis, either chronic or of the recurring type. 

ACUTE BRONCHOPNEUMONIA. 

Bronchopneumonia, also known as catarrhal and lobular 
pneumonia, is one of the common diseases of childhood, pre- 
senting a mortality rate exceeded only by diarrheal diseases, 
and prevailing particularly before the fourth year of life. 

Etiology. — There are two forms of bronchopneumonia, 
namely, primary and secondary. Primary bronchopneumonia 
occurs especially in infants debilitated by previous illnesses, or 
in those suffering from rickets or marasmus. Atmospheric 
changes are the chief exciting cause, as the greater prevalence 
of this disease during the winter and early spring months clearly 
indicates. Primary bronchopneumonia is less frequently seen 
after the fourth year, being essentially a disease of early child- 
13 



178 DISEASES OF CHILDREN 

hood. It may, however, develop from the extension of a severe 
bronchitis at any age. 

Secondary bronchopneumonia is a frequent complication of 
the acute infectious fevers, especially of the exanthemata, 
diphtheria, whooping-cough and influenza. 

Bacteriological research indicates that primary broncho- 
pneumonia is nearly always due to the pneumococcus, while 
secondary bronchopneumonia results from a mixed infection, 
in which the streptococci play the most important role. When 
complicating diphtheria the Klebs-Loffler bacillus is the excitant 
of the pathological process ; the influenza bacillus may also cause 
bronchopneumonia. 

Pathology. — In the larger bronchi a superficial inflam- 
mation is encountered while in the smaller tubes the entire wall 
shares in the pathological process, and we find here both 
bronchitis and peribronchitis. The characteristic lesions are in 
the air vesicles, which in typical cases are distended with 
cellular exudate. The cells are mainly swollen, desquamated 
epithelia with small nuclei. Red blood corpuscles and leuco- 
cytes are also found in variable number. Fibrin, as a rule, is 
scant; often entirely absent. The fibrin in these cases is 
difficult to demonstrate, as the threads are rendered indistinct 
through the presence of a large number of leucocytes (Ziegler). 
In the aveolar septa and peribronchial connective tissue the 
blood vessels are distended with red blood corpuscles and these 
structures are infiltrated with large mononuclear leucocytes. 

Taking into consideration the above histological changes 
in the pulmonary tissue it is self evident that resolution must 
be often delayed, leading to permanent tissue changes. The 
co-existing bronchitis in the finer tubes explains the suffocative 
symptoms which may arise in capillary bronchitis. 

Mixed types of pneumonia occur, in which one portion of the 
lungs is the seat of typical catarrhal and interstitial inflammation 
while another portion is consolidated by purely croupous exu- 
dation. These cases pursue more closely the clinical course of 



DISEASES OF THE RESPIRATORY TRACT 179 

bronchopneumonia than lobar pneumonia, but it requires 
microscopic examination to recognize the true character of 
the lesions. 

Small bronchopneumonic areas representing consolidated 
alveoli may spread and become confluent, thus invading an 
entire lobule and giving rise to a lobular pneumonic process. 
These lobular areas are in the majority of cases separated by 
streaks of uninvaded lung tissue, i.e., lobules still pervious 
to air. An entire lobe may, however, become invaded, in which 
case we are confronted with a bronchopneumonia of lobar dis- 
tribution (Ziegler). 

The exudate in some instances is hemorrhagic in character. 
When resolution is delayed it frequently becomes purulent 
owing to the presence of a large number of leucocytes that have 
undergone degeneration. 

Bronchopneumonia may abort in the early stage before con- 
solidation can be detected and thus run the course of a severe 
bronchitis, or it may assume the clinical characteristics of a 
lobar pneumonia. Again, instead of undergoing resolution the 
inflammatory process may progress and interstitial pneumonia 
be the result. 

The pathological findings are by no means uniform and as 
Delafield has pointed out the consolidated lobules may bear no 
definite relationship to the bronchus leading to them. The 
inflammation is diffuse in character, and lobule after lobule 
may become consolidated without its communicating bronchus 
being simultaneously involved. The inflammation therefore 
travels through contiguity of structure as well as by contin- 
uity thereof. 

In the early stage (red pneumonia) the lung is engorged and 
of an intense red color. On section, a bloody, frothy fluid 
exudes from the air cells. The bases are heavier and darker 
in color owing to hypostatic congestion. Consolidation has not 
yet taken place, but microscopic examination reveals cell- 
proliferation in the peri-bronchial connective tissue and septa 



180 DISEASES OF CHILDREN 

and catarrhal and hemorrhagic exudate in the alveoli. The 
process may abort here, prove fatal, or go into the stage of 
mottled or red and gray pneumonia, representing the fully 
developed process. If the lung is examined at this stage, both 
the surface and the sections will present a mottled appearance 
due to the admixture of consolidated (gray) and congested 
(red) areas. The process may involve an entire lobe or appear 
only in patches dispersed through the otherwise normal lung 
tissue. Wherever a bronchus has become occluded areas of 
atelectasis are seen. 

If resolution be delayed or arrested, the so-called gray pneu- 
monia results. In these cases the lung is somewhat enlarged, 
gray in color and extensively consolidated. Pleural thickening 
and adhesions are common. On section a mucopurulent exudate 
covers the cut surface. The bronchial walls and the interstitial 
tissue are hyperplastic and areas of atelectasis and compen- 
satory and interstitial emphysema lie interspersed between the 
consolidated areas. 

In the cases that recover the termination is resolution through 
expectoration and resorption of the exudate; in unfavorable 
cases suppuration; interstitial induration; gangrene. 

Resolution may begin before consolidation can be detected. 
Ordinarily it is completed in from two to three weeks. When 
delayed, there is a strong tendency to incompleteness of the 
process. In recurring attacks, permanent interstitial changes 
are apt to remain. 

The pleura shares in the inflammatory process when the 
lesions are superficial. Fibrinous and fibro-purulent exudate 
is poured out upon the surface of the visceral pleura with the 
consequent development of adhesions and thickening. In some 
instances the pleuritic process becomes a prominent feature of 
the case (pleuro-pneumonia). This is more common, however, 
in the lobar type of the disease. 

Symptoms. — Primary bronchopneumonia begins clinically 
as a bronchitis in the majority of cases. Instead of advancing 



DISEASES OF THE RESPIRATORY TRACT 181 

favorably, however, there develops progressively increasing 
dyspnea and rapid breathing, increase in fever and pulse-rate, 
and prostration. 

Some cases begin, like lobar pneumonia, abruptly, with chill, 
high fever, rapid breathing and pronounced nervous disturb- 
ance (toxemia). They may prove fatal before signs of 
pulmonary inflammation have had time to develop; even cough 
may be absent. At the autopsy the lungs are found intensely 
congested and edematous. 

In young infants bronchopneumonia may come on insidiously, 
fever being slight during the entire course. The main symp- 
toms are cough, progressively increasing cyanosis and rapid 
respirations. As a rule, gastro-intestinal symptoms accompany 
the pneumonia. The prognosis is grave. 

During the progress of the disease the child emaciates 
markedly and carbonization of the blood becomes apparent. 
The pulse is rapid and weak, and the heart may eventually 
fail in its work if the pulmonary obstruction is extensive. 

Cough is a prominent symptom; in the beginning it is hard 
and dry; later it sounds loose but since young children are 
unable to expectorate the cough gives little relief. Much of the 
mucus, however, is swallowed. 

Respiration is often accompanied by fan-like movements of 
the alse nasi and recession of the soft parts of the thorax, notably 
its lower portion. In rachitic infants serious deformity of the 
chest results. 

When bronchopneumonia develops during the course of one 
of the infectious fevers it is to be suspected from an increase in 
the fever, increased rapidity of breathing and pulse-rate, cough 
and dyspnea, especially the latter. 

Bronchopneumonia tends to localize itself in certain areas 
of the lungs, in this way differing from simple bronchitis in 
which the process is general. 

In the absence of signs of consolidation, the height and 
duration of the fever are the symptoms upon which we must 



182 DISEASES OF CHILDREN 

rely in diagnosing bronchopneumonia. Cabot states that 
bronchopneumonia should be suspected in the adult when the 
patient is too sick to have bronchitis, and this applies with equal 
force to children. 

Bronchopneumonia is progressive in its development, being 
slower both in its onset and in the development and resolution 
of its pathologic products than lobar pneumonia. Its course 
sometimes extends over several weeks, and protracted cases are 
common, especially in the debilitated. 

Meningeal symptoms, either of toxic origin or due to an 
associated meningitis, may occur, but are not as commonly en- 
countered as in lobar pneumonia (see "Cerebral Pneumonia"). 

Death results from respiratory or cardiac failure; some- 
times from hyperpyrexia. Collapse is the commonest termina- 
tion; sometimes death occurs with convulsions or coma. The 
fulminating cases die from toxemia. 

The prognosis must always be guarded, as can be seen from 
the high mortality rate. It is especially grave when the child 
is very young and debilitated, or when the disease is secondary 
to a condition in itself dangerous. The pulse and respiration 
are the main indications of the child's condition. A continuous- 
ly high temperature is more dangerous than one in which 
remissions occur. Cyanosis is always a grave symptom. The 
soft condition of the chest-wall in rickets makes breathing very 
difficult in pneumonia and rachitic children stand the 
disease badly. 

A grunting expiration is said to indicate atelectasis, but 
is not necessarily a bad symptom, unless very pronounced and 
persistent. It may be due to an associated pleurisy. The cough 
is also a guide to prognosis ; when it becomes weak and ineffec- 
tual and mucus collects in the larger tubes it is usually a sign 
of oncoming respiratory failure. 

Diagnosis. — The physical signs are those of bronchitis of 
the larger and smaller tubes associated with consolidation of 
scattered areas of pulmonary tissue of varying size and extent. 



DISEASES OF THE RESPIRATORY TRACT 183 

They are best elicited posteriorly, the child being held over the 
nurse's shoulder. One may detect large and small moist rales ; 
subcrepitant rales; tubular breathing and dullness over the 
consolidated areas of sufficient extent to convey these signs 
(usually the bases of the lungs) ; diminished breathing over 
areas of atelectasis, and exaggerated breathing in the vicariously 
emphysematous lung. In the absence of distinct physical 
signs, however, the presence of fever, cough, rapid labored 
respirations and prostration are sufficient clinical evidence 
upon which to make a diagnosis of bronchopneumonia. 

From croupous pneumonia it is distinguished by its gradual 
onset, tedious course, bilateral distribution, absence of extensive 
lobar consolidation, and its occurrence in the very young and in 
the feeble, croupous pneumonia Usually attacking those in 
apparently good health and of more mature age. In capillary 
bronchitis there are fine moist rales generally distributed 
throughout the chest. There is, however, no sharp line of 
demarcation between the pathology of the two affections. Tuber- 
culosis is more gradual in onset and when physical signs develop 
they are more prominent in the apices than at the bases. There 
is no tendency toward recovery as in bronchopneumonia and 
the dyspnea is out of proportion to the physical signs present. 
Other evidences of tuberculosis may be detected, such as the 
signs of enlarged bronchial glands, and the sputum may show 
the presence of tubercle bacilli. 

Treatment. — The child should be put to bed, and its position 
changed regularly to avoid adding hypostatic congestion to the 
already seriously crippled condition of the lungs. Infants can 
be taken up by the nurse during coughing paroxysms and held 
face downward or on the side to facilitate the expulsion of the 
bronchial secretion. The room must be thoroughly ventilated, 
and a temperature of about 60 to 65 degrees maintained. The 
"cold air" treatment is contraindicated in cases with much 
bronchitis but it is of decided value in the croupous type of 
pneumonia. In cases of "capillary bronchitis" it is important 



184 DISEASES OF CHILDREN 

to moisten the air in the immediate vicinity of the child. This 
is best accomplished by means of the croup-kettle or steam spray. 
High fever is best combated by fresh air, cool or tepid sponge 
baths and bowel irrigations. In hyperpyrexia a cold pack may 
be used. When carbonization of the blood becomes manifest 
and the bronchial tubes become clogged with secretion, the 
alternate application of hot and cold packs to the chest should 
be resorted to. A warm full bath, followed by a cool sponge 
bath, is frequently useful to relieve the pulmonary congestion. 

Oxygen inhalations may be employed in serious cases. From 
one to two gallons (bagfuls) administered by holding a glass 
funnel attached to the tube from the water bottle of the ap- 
paratus over the child's mouth and nose may be given every 
hour. There is no objection to enveloping the chest in a cotton 
jacket if the sick room is to be kept cool and if there is an 
associated pleurisy. When, however, the child is kept in a warm, 
moist atmosphere on account of the bronchitis and cough, care 
should be exercised not to have it overdressed. 

In case of collapse, brandy or aromatic spirits of ammonia 
may be resorted to. Camphorated oil, five minims, hot packs 
to the chest, and oxygen should be used if the collapse and 
cyanosis persist. It may become necessary to use brandy or 
whiskey regularly in small doses in protracted cases with failing 
circulation. 

The remedies most frequently indicated in the early stages 
are aeon., bell., bry., ferrum phos., ipecac and scilla; for 
the later manifestations, especially the unfavorable symptoms 
likely to arise, tartar emetic, phos., arsen., carba veg. and 
veratrum alb. are called for. 

Aconite should always be studied in comparison with verat- 
rum viride and ferrum phos. All three are indicated early in 
the disease, when there is high fever and a teasing cough, with 
little or no expectoration — the stage of congestion. Aconite 
is distinguished by its great anxiety and restlessness, thirst, 
and aversion to being touched or moved, which induces suffering; 



DISEASES OF THE RESPIRATORY TRACT 185 

veratrum viride by its vascular excitement and respiratory 
embarrasment, bloodshot eyes and cerebral irritation; ferrum 
phos. by the absence of either nervous erethism or high 
arterial tension and by its characteristic frothy, blood-streaked 
expectoration. 

Arsenicum is indicated by extreme prostration and restless- 
ness; dyspnea from the slightest exertion; thirst for small 
quantities of water, the mouth being dry and the tongue and 
lips cracked; diarrhea; cold surface. 

Belladonna is particularly valuable when nervous disturb- 
ances are pronounced. Its excellent effect in capillary 
bronchitis makes us think of it in pneumonia when the bronchial 
symptoms predominate. Belladonna is homeopathic to the 
vascular engorgement and high temperature so prominent in 
many cases. 

Bryonia is of the greatest service to loosen the cough, control 
the pain, and check the extension of the process into the smaller 
tubes and promote the absorption of the exudation. It must 
be differentiated from scilla, which is similar in many respects, 
but more suitable to grave cases marked by progressively- 
increasing prostration and dyspnea; rapid, weak pulse; short, 
painful cough, causing the child to cry faintly after each parox- 
ysm ; in fact, it cannot be moved without giving it pain. Hale 
{Practice of Medicine) considers scilla the remedy above all 
others after aconite and belladonna, being in every respect 
homeopathic to bronchopneumonia. 

Ipecac is the remedy where the bronchial element predom- 
inates and the chest seems literally filled with mucous secretion, 
subcrepitant rales being heard everywhere in abundance. The 
cough is troublesome and gagging, giving little relief. The 
secretion gradually collects to such an extent in the finer bronchi 
that suffocation becomes imminent. In this regard it differs 
from tartar emetic, which represents a state of carbonic acid 
poisoning, in which mucus, collecting in the larger tubes, 
produces the characteristic rattling, or in which there is active 
pulmonary edema. 



186 DISEASES OF CHILDREN 

Phosphorus. — 'Where consolidation predominates over the 
bronchial symptoms, together with active congestion, producing 
a tight, distressing cough ; rapid, shallow respirations ; tightness 
across the upper portion of the chest ; blood tinged expectoration ; 
failing right heart. We are inclined to think of phosphorus 
only in lobar pneumonia, but it is of equal value in the lobular 
variety when we have to deal with congestion, consolidation and 
toxemia; in fact, some old school writers (Wood) recommend 
phosphorus as a nerve tonic in the adynamia of pneumonia. 

Sulphur is similar to phosphorus in its effect on consolidation, 
but it has a greater power of removing the same. Phosphorus 
mainly controls the vascular disturbance. Sulphur is indicated 
in the later stages of bronchopneumonia. 

CROUPOUS PNEUMONIA. 

Croupous, or lobar pneumonia, is a primary acute infectious 
disease in which one or more of the pulmonary lobes are consoli- 
dated by a croupous exudate. It is a self-limiting disease and 
is not accompanied by bronchitis. 

Etiology. — Croupous pneumonia is most frequently seen 
after the third year, and usually attacks those of previously 
good health, unlike bronchopneumonia, which attacks with 
predilection those already debilitated or develops in connection 
with the acute infectious diseases. I have, however, encountered 
it in infants as young as two and three months old. Fatigue 
and exposure to cold act prominently as predisposing causes. 
While the dry, cold months, particularly the early spring, 
furnish the largest number of victims, still pneumonia may be 
seen at any time of the year, like all other infectious diseases. 
Boys are more often attacked than girls. 

Recently, studies of the organisms present in pneumonia in 
children have been made with the purpose of determining the 
type of pneumococcus responsible for the different cases. Pisek 
and Pease (Amer. Jour. Med. Sciences, 1916), found type 1 
nine times, type 2 eleven times, type 3 once, type 4 seven times 



DISEASES OF THE RESPIRATORY TRACT 187 

in twenty-eight cases studied. Wollstein and Benson (Amer. 
Jour. Dis. Child., 1916), found type 4 in 60 per cent of the 
cases with a mortality of 40 per cent. This is quite different 
from the findings in adults in whom type 4 is not often fatal. 

Pathology. — In typical cases of croupous pneumonia one 
lohe is affected in its entirety. The most frequently consolidated 
lobe is the left lower; next in frequency come the right lower 
and the right upper lobes. The right middle and the left upper 
are the least often attacked. 

Some degree of plastic pleurisy is always associated. When 
the lower left lobe is affected and the pleura is involved the 
process may spread to the pericardium. The pleural inflam- 
mation may become so prominent as to influence notably the 
clinical course of the disease. 

At the onset of pneumonia, the stage of engorgement, the 
affected lobe is bright red, greatly congested and somewhat 
edematous. The lung appears enlarged, as if inflated, and 
when the inflammatory exudate fills the alveoli and solidifies, 
the consolidated lobe is actually larger than normal, for which 
reason the area of dulness elicited by percussion may be of 
greater extent than that which the lobe normally occupies. 

On microscopic examination the alveoli appear engorged, 
the bloodvessels encroaching upon their lumen. A small amount 
of serum and leucocytes has been poured out and the exudation 
becomes more and more rich in cells and fibrin and more 
hemorrhagic in character as the process goes on. At this time 
the crepitant rale is most clearly heard. The alveoli eventually 
are distended to their utmost with red and white blood cor- 
puscles embedded in a stroma of fibrin. The fibrin also fills 
the lymphatics in the interstitial connective tissue, and it can be 
seen communicating by thin bands through the pores of the 
alveoli. This period represents the stage of red hepatization. 

The color of the lung gradually changes from red to gray, 
owing to the compression of the bloodvessels of the alveoli by 
the exudate and to the degeneration of the cellular elements. 



188 DISEASES OF CHILDREN 

This stage is called gray hepatization. Later the exudate is 
gradually removed by the lymphatics, some being expectorated 
after having undergone softening, and resolution is thus estab- 
lished. In the usual cases resolution becomes complete and the 
lung is restored to its normal condition. 

During consolidation the lung is quite friable and cuts like 
liver. On the surface of the section small plugs of hardened 
fibrin filling the alveoli and independent therefrom are seen, 
giving it a granular appearance. In children this does not show 
as typically as in adults, owing to the lesser development of the 
air cells. At times, owing to a gradual spread of the process, 
all stages, that is, red and gray hepatization and beginning 
resolution, may be encountered in a section of a single lobe. 

When resolution is delayed it may terminate in suppuration 
with abscess formation, gangrene, caseation. Complete recovery 
is, however, the rule, excepting in cases complicated with pleural 
inflammation, in which it is common for an empyema to 
develop secondarily. 

Symptoms. — The onset of croupous pneumonia is character- 
istically sudden, and the course of the disease is acute through- 
out ; sudden onset, high temperature, with but slight remissions 
and termination within from six to eight days by crisis are the 
features of a typical case. In the majority of cases the crisis 
occurs on the seventh day. 

The initial symptom is a chill, which may be replaced by a 
convulsion in young children. Sometimes vomiting is the sole 
symptom. In young children the chilly stage becomes manifest 
by a cyanotic pinched appearance and noticeably cold hands and 
feet. The temperature rises rapidly, soon reaching a height 
of 104 degrees or higher; the pulse is rapid and full, and the 
respirations are strikingly increased, exceeding the normal ratio 
between pulse and respiration. Thus, with a pulse of 120 there 
will be 60 or more respirations, while the normal ratio is one 
respiration to four heartbeats. The temperature range may 
vary between 102.5° to 105°. Remissions are more pronounced 
than in adults. 



DISEASES OF THE RESPIRATORY TRACT 189 

Associated with the fever there is restlessness ; dry, hot skin ; 
headache and some delirium toward night, and a dry, painful 
cough. The face wears a characteristic distressed expression. 
When there is considerable involvement of the pleura the painful 
cough becomes a prominent feature of the case. When the 
parietal pleura of the chest wall is inflamed, there results a 
sharp stabbing pain at the site of the inflammation which is 
made worse by coughing, deep breathing or even muscular 
movements affecting the chest wall. Capps has shown that when 
the diaphragmatic pleura is inflamed at the peripheral portion 
of the diaphragm, the pain is referred to the lower portion of 
the thorax and to the abdomen, as the result of irritation of 
filaments of the lower intercostal nerves. This has frequently 
led to the erroneous diagnosis of an abdominal affection, notably 
of appendicitis, when the right lower lobe is affected. With 
involvement of the central portion of the diaphragm the pain 
is referred to the neck and may cause symptoms likely to be 
confused with meningitis (rigidity of the neck). 

Within from two to four days the process of consolidation is 
generally complete, as can be demonstrated by the dulness and 
bronchial breathing observed over the affected area. With the 
crisis, which may appear on any day from the fifth to the ninth, 
oftenest, however, on the seventh day, there is a marked amelio- 
ration of all symptoms. A profuse sweat accompanies this 
sudden fall in temperature, and at times, indeed, there occur 
quite alarming symptoms of collapse, calling for immediate 
action. After the crisis the process of resolution becomes estab- 
lished, being completed in from five days to a week in the 
average case. A rise of temperature during this time — in other 
words, a post-critical rise — indicates the development of some 
complication, such as pleurisy, empyema, meningitis, peri- 
carditis or the extension of the pneumonic process to other 
portions of the lungs. A pseudo-crisis is common in children; 
it usually occurs on the fifth day. Termination by lysis is more 
frequent in children than in adults, but is atypical. A pro- 



190 DISEASES OF CHILDREN 

tracted course means a complication, usually an associated 
pleurisy. Marked remissions in the temperature are also more 
common in children than in adults. When pronounced these 
cases are described as remittent pneumonia. 

The blood changes are important. While there is but a slight 
anemia, leucocytosis develops to a marked degree. A pro- 
nounced leucocytosis indicates a severe infection in an organism 
capable of good reaction. There is usually a rise in the leucocytes 
to 20,000 and over. Leucocytosis offers a reliable sign of 
differential diagnosis between pneumonia and such conditions 
as acute typhoid septicemia, influenza, caseous pulmonary 
tuberculosis and serous pleurisy, it being absent in these con- 
ditions. It is of no value, however, in the differentiation of 
croupous pneumonia from bronchopneumonia, empyema and 
cerebrospinal meningitis. 

Many severe cases of pneumonia present a clinical picture 
so different from the group of symptoms above enumerated that 
they merit separate description, being classified into the fol- 
lowing varieties: 

Cerebral pneumonia. — This form is characterized by rapid 
onset with fever, convulsions or vomiting, and a predominance 
of cerebral symptoms during the entire course of the disease. 
In children over three years old convulsions may be absent, but 
delirium and coma develop. Symptoms simulating meningitis, 
such as stupor, strabismus, opisthotonus, slow irregular pulse, 
dilated pupils, and convulsions, are a frequent accompaniment 
of the severe types of pneumonia, and there seems to be a close 
clinical relationship between pneumonia of the upper lobes and 
cerebral symptoms. The pneumonic process is slow to develop 
in many cases, and often the consolidation cannot be detected 
until the fourth or fifth day, for which reason meningitis is 
suspected. The brain symptoms rapidly subside after the 
crisis. In cases of meningitis complicating pneumonia the 
brain symptoms develop during the course of the pneumonia 
and are not present at the time of onset, and are uninfluenced 
by the crisis. 



DISEASES OF THE RESPIRATORY TRACT 191 

Wandering pneumonia. — Another form of pneumonia 
worthy of mention is the so-called wandering pneumonia, in 
which the pneumonic process spreads from its original seat to 
other portions of the lung, resolution going on at one point while 
a fresh invasion occurs in another. 

Central pneumonia is of special interest from the diag- 
nostic standpoint, since it has long been held that cases of 
pneumonia in which physical signs are absent or late in devel- 
oping are of this type and that the pathological process begins in 
the central portion of the lung and gradually extends to the 
surface. This, however, is a pathological fallacy and the X-ray 
has demonstrated that the shadow cast by a pneumonic consol- 
idation is triangular in shape with the base in the axilla and the 
apex toward the hilum. As soon as the consolidation extends 
far enough down into the parenchyma of the lung to come in 
contact with a large bronchus, bronchial breathing will be heard, 
but prior to that time there will be no distinct evidence of 
pulmonary consolidation (Mason, Amer. Jour. Dis. Child., 
1916. 11). It is clear that these cases cannot be diagnosed 
until there is sufficient basis for their recognition. Grave 
symptoms may exist with only a small amount of consolidation, 
the toxemia being entirely out of proportion to the exist- 
ing lesion. 

Pneumonia with Gastrointestinal Symptoms. — One of 
the characteristic features of pneumonia in young children is 
the prominence of gastrointestinal symptoms. These may 
completely mask the clinical picture, so that the pneumonia is 
not suspected. Vomiting, diarrhea, distended abdomen and 
high fever not responding to appropriate treatment directed to 
the alimentary tract should arouse a strong suspicion of pneu- 
monia and lead to a careful examination of the chest. The 
grunting respiration of the pneumonia may be mistaken for 
the child's ineffectual urging to stool, or be interpreted as an 
embarrassment of respiration resulting from the tympanites, 
thus adding to the confusion. 



192 DISEASES OF CHILDREN 

Influenzal pneumonia may be due either to the Pfeiffer 
bacillus or result from secondary infection with the pneumo- 
coccus or streptococcus during an attack of grippe. These cases 
begin as an influenzal bronchitis, during the course of which 
one or more pulmonary lobes become consolidated. The course 
is graver and more protracted than in primary lobar pneumonia. 

Abortive pneumonia is rare in children. Cases are encoun- 
tered which terminate in from four to five days; they might 
be called mild cases. Again, the process may not go beyond the 
first stage, and although congestion of a single lobe and pneu- 
mococci in the sputum can be demonstrated, consolidation 
fails to take place, the process actually aborting, as other acute 
infections sometimes do. It is needless to say that the diagnosis 
is beset with great difficulty. There are also fulminating cases, 
terminating fatally in the first twenty-four hours. 

Typhoid-pneumonia. — This misleading term refers to that 
type of pneumonia in which the patient sinks into a typhoid 
state as the result of the toxemia. Instead of active brain symp- 
toms being present as in cerebral pneumonia there is apathy and 
prostration ; dry, coated tongue ; tympanites ; involuntary stools ; 
muttering delirium; subsultus tendinum. Rose-spots, enlarged 
spleen and Widal reaction are absent. Typhoid fever, however, 
may be complicated with pneumonia. In doubtful cases blood 
cultures should be made. 

Pleuro-pneumonia is a form of pneumonia (6.8 per cent in 
Holt's series of 398) in which pleurisy coexists with the pneu- 
monic process and to such an extent as to affect the clinical 
course of the disease in a decided manner. The pleural 
inflammation is chiefly plastic in nature and the growth of 
serum poured out is relatively slight; never so great as seen in 
a primary pleurisy. At the autopsy the pleural surfaces are 
found matted together and' covered with a thick, yellow, plastic 
exudate that can be readily scraped off and from the interstices 
of which turbid serum exudes. 

The surface of the entire lung on one side may be covered 



DISEASES OF THE RESPIRATORY TRACT 193 

with this exudate even though only one lobe be consolidated. 
The changes in the lung are not necessarily lobar, but may be 
bronchopneumonic in type. Cases which recover develop a 
subsequent empyema. The mortality rate is very high. 

In the first stage there is every evidence of a beginning 
pneumonia, together with severe pain in the side and the 
physical signs of pleurisy. Friction sounds are plainly heard 
and in the course of a few days distinct dulness, bronchial 
breathing and bronchophony can be detected. These latter signs 
are somewhat obscured by the thick fibrinous layer, but never 
to the extent produced by an effusion. Aspiration is negative, 
but the symptoms are too severe for a simple pleurisy and too 
indistinct for a frank pneumonia. The prognosis is unfavorable, 
especially in young children. Pericarditis is a common compli- 
cation. Cases that survive may have to go through the course 
of an empyema with possibly severe crippling of the lung. 
When, however, the process remains localized, perfect recovery, 
barring adhesions, is possible. 

Complications. — A certain amount of pleurisy accompanies 
all cases of pneumonia. Pleural effusions, both serous and 
purulent, are, more strictly speaking, sequelse; they are much 
more common in children than adults. Otitis is rare; it is, 
however, frequently seen as a complication of bronchopneu- 
monia. Meningitis is more likely to occur late in the case. 
Cerebral symptoms coming with the onset or early in the case, 
are more likely to be of toxic origin. Pericarditis is a grave 
complication ; it is seldom recognized in vitam. Other compli- 
cations that may develop are myocarditis, endocarditis, periton- 
itis, gastro-enteritis, arthritis, septico-pyemia. 

Physical Signs. — The physical signs in lobar pneumonia 
vary with the different stages of the pathological process. The 
duration, clinical course and complications also modify these 
signs as well as the age of the child. 

In the first stage the child appears flushed with fever and 

the respirations are quickened. There is characteristically a 
14 



104 DISEASES OF CHILDREN 

short inspiration followed by a pause and then a quick panting 
or moaning expiration. The pulse^respiratory ratio are changed 
from the normal 1 to 4 to 1 to 2. 

Over the affected lobe the respiratory sounds are feeble, 
sometimes almost suppressed, while percussion reveals a slight 
dulness of tympanitic quality. On the opposite or well side the 
breath sounds may be harsh and exaggerated, often leading to 
the error of suspecting the lesion on the well side. On coughing 
the crepitant rale may be heard. 

Friction rales, pleural in origin, are frequently heard. An 
interesting observation has been made by Shaw (Archives of 
Pediatrics Aug., 1903), who found that the crepitant rale and 
friction can be distinctly heard over the abdomen when the 
lower lobes are affected. 

Second Stage. — With the completion of consolidation vocal 
fremitus is increased over the affected lobe and percussion 
dulness becomes pronounced. The area of dulness apparently 
covers a larger area than the anatomical boundaries of the lobe 
allow for. This is explained by the fact that the croupous 
process distends and enlarges the lobe. When pleural effusion 
takes place the lower portion of the dull area becomes flat. 
It is not uncommon to hear friction sounds in the lower part of 
the chest, posteriorly and laterally, in pneumonia in this region. 
The adjoining normal lung, through compensatory emphysema, 
may give the vesiculotympanitic note. Auscultation reveals 
bronchial breathing and bronchophony. 

Third Stage. — As resolution sets in and the exudation begins 
to soften, crepitation reappears (crepitatio redux). Moist rales 
are usually added and considerable of the exudate is coughed 
up. Bronchial breathing persists longer than actual consolida- 
tion; so also dulness. This is no doubt due to the relaxed and 
congested state of the pulmonary tissue. For this reason it is 
possible to demonstrate abnormal physical signs for some days 
after the crisis. We must, however, regard with suspicion the 
persistence of pronounced dulness and diminished or absent 



DISEASES OF THE RESPIRATOEY TRACT 195 

respiratory murmur after pneumonia. Delayed resolution 
should always suggest the probability of fluid being present. 

Prognosis. — In infants the prognosis is less favorable than 
in older children. Eobust children from three to ten years old 
recover as a rule. Indeed, the mortality rate at this period of 
life is strikingly lower than in adults. The type of organism 
responsible for the infection bears a strong relationship to 
the prognosis. 

Of primary importance in gauging the prognosis is the 
degree of toxemia. This seems more important than the extent 
of the pulmonary involvement or the height of the fever. Nat- 
urally, the spread of the disease to adjacent portions of the lung 
is unfavorable. The heart holds out better than in the adult 
because the child's circulatory apparatus can adapt itself to 
increased circulatory obstruction better than the adult's. 

The majority of deaths occur at the height of the disease. 
When death occurs later it is the result of one of the above 
mentioned complications. 

Diagnosis. — Whenever we are confronted with an acute 
condition of sudden onset with high fever preceded either by 
a chill, vomiting or a convulsion, we should first examine the 
throat. If this is found to be negative the chest should be 
carefully investigated. Many cases of high fever of sudden 
onset clear up in a day or two, and cannot be accounted for. 
Sometimes an acute otitis causes symptoms simulating the onset 
of pneumonia, even convulsions being present, all, however, 
clearing up after the ear begins to discharge. We should 
always suspect the lungs in the presence of continued high fever 
and increased respirations, especially if the expiration is of the 
characteristic moaning type. 

The conditions from which pneumonia is to be differentiated 
are bronchopneumonia, pleurisy, meningitis and caseous tuber- 
culosis. Broncho pneumonia is essentially bronchial in origin, 
both etiologically and pathologically, and its course is long and 
protracted, independent of complications. In pleurisy the 



196 DISEASES OF CHILDREN 

physical signs are essentially different and the onset gradual. 
The fever is not so high and terminates by lysis. Besides, 
primary pleurisy with effusion is rare in children, but pleuritic 
inflammation with purulent exudate secondary to pneumonia 
is common. 

In meningitis symptoms are continuous and protracted. 
Death is practically always the termination excepting in the 
epidemic cerebro-spinal variety. Meningitis complicating 
pneumonia occurs in the later stages of the disease; cerebral 
symptoms occurring at the height of pneumonia are toxic and 
disappear by crisis or even before the crisis. 

Typhoid fever beginning abruptly may cause confusion. 
The absence of leucocytosis and the later appearance of rose 
spots, the Widal reaction and enlarged spleen positively iden- 
tifies it. 

Acute caseous pulmonary tuberculosis may set in with a 
chill and lead to the consolidation of an entire pulmonary lobe 
within a remarkably short time. The temperature will run high 
and the entire clinical picture be identical with that of croupous 
pneumonia. Crisis does not occur, however, and eventually 
softening and break down of pulmonary tissue sets in. Elastic 
fibres and tubercle bacilli can be detected in the sputum at this 
time, confirming the diagnosis. The most experienced are 
deceived, however, in the early stage of such a case. 

Treatment. — The treatment of croupous pneumonia is essen- 
tially the same as that recommended for bronchopneumonia. 
The fresh air treatment may be carried out without restriction, 
as there is no contraindication to cold air like in some cases of 
bronchopneumonia. There are certain remedies which are 
especially related to croupous exudations, in contradistinction 
to those of a purely catarrhal type, and they will, therefore, be 
more useful in croupous than bronchopneumonia. Thus, ipecac 
and tartar emetic are less frequently indicated than bryonia and 
sulphur. In the early stages aconite is the most useful drug. 
When blood streaked sputum is present ferrum phos. may be 
used as a routine remedy. 



DISEASES OF THE RESPIEATORY TRACT 197 

Iodine is recommended by Kafka (Homeopatische Therapie) 
as being truly homeopathic to the croupous exudation, as well as 
to most of the symptoms. 

The high fever and cerebral symptoms will call for bella- 
donna or veratrum viride. 

Bryonia is especially valuable in pleuropneumonia. 

Although phosphorus is more useful in bronchopneumonia 
than in croupous pneumonia, still it is of good service where 
there is marked congestion indicated by dyspnea; tightness 
across the upper portion of the chest; bloody expectoration; 
failing right heart and profound toxemia. 

Sulphur is the chief remedy to aid resolution, being especially 
useful in the third stage of pneumonia. 

Arsenicum is well suited to those atypical cases in which the 
poison of influenza is added to that of pneumonia. In the 
presence of abundant bronchial secretion with dyspnoea and 
cardiac weakness, the iodide of arsenic is preferable. 

Special symptoms are to be dealt with as directed under 
bronchopneumonia, 

PULMONARY TUBERCULOSIS. 

Tuberculosis of the lungs in childhood is encountered in a 
variety of forms which may be either acute or chronic in their 
course. During infancy acute miliary tuberculosis of the lungs 
and acute tuberculous bronchopneumonia are the types usually 
seen. Older children show more resistance toward the tubercle 
bacillus and as a rule the infection remains latent at this time 
of life. When this is the case the clinical manifestations are 
chiefly those of involvement of the bronchial glands. A tuber- 
culous bronchopneumonia, however, of less acute course than 
in infancy may be encountered at this age. During late child- 
hood the open form of chronic pulmonary tuberculosis, or 
phthisis is seen as in the case of adults but it does not become 
a common affection until the period of adolescence is reached. 

Acute Miliary Tuberculosis. — During infancy a dissem- 



198 DISEASES OF CHILDREN 

mated miliary tuberculosis is a frequent terminal condition 
developing secondarily from a primary focus of infection in 
the lung. The bronchial glands are incapable of arresting the 
infection as in the case of older children and for this reason 
miliary tuberculosis readily develops in an infant. Miliary 
tuberculosis of the lungs may also be a terminal event in a case 
of chronic pulmonary tuberculosis in an older child. 

Tuberculous bronchopneumonia may be encountered at 
any period of childhood and it may occur primarily from the 
extention of the infection in a bronchial gland or it may develop 
secondarily after an attack of bronchopneumonia or an acute 
infectious disease. From the standpoint of the pathologist 
bronchopneumonia always develops secondarily to a primary 
focus of infection in the lungs and bronchial glands. Such 
apparent exciting causes as an attack of pneumonia or measles, 
for example, act through lowering the child's resistance and in 
aiding the breakdown and extension of the primary lesion. 
There are two types of tuberculous pneumonia, namely the 
bronchopneumonia type and acute caseous tuberculous pneu- 
monia. In the former, tuberculous nodules and caseous areas 
of varying size are formed throughout the lungs, one lung, 
however, usually being more involved than the other. These 
areas of consolidation more frequently occur in the upper lobes 
than in non-tuberculous bronchopneumonia. In some instances 
a lower lobe may rapidly become caseous throughout, thus 
simulating lobar pneumonia. Instead of resolution, however, 
setting in as in the case of the latter disease the lung eventually 
breaks down and cavities may form in the consolidated area. 
The consolidation results from epithelial infiltration of the 
alveoli (desquamative pneumonia). Bronchitis and peribron- 
chitis are associated processes. The solidified areas undergo 
caseation and these in turn break down as a result of necrosis or 
secondary infection with pyogenic organisms. 

Symptoms. — Tuberculous bronchopneumonia may develop 
primarily by extension from infected bronchial glands or it may 



DISEASES OF THE RESPIRATORY TRACT 199 

occur as a sequel to some acute infectious disease or after an 
unresolved pneumonia. It presents the symptoms of an or- 
dinary bronchopneumonia in its early stage, there being cough, 
continued fever and the physical signs of bronchitis and areas 
of pulmonary consolidation. The apices are more frequently 
involved than the bases of the lungs and the sign of d'Espine 
can usually be demonstrated. At first dulness and persistent 
subcrepitant rales in the consolidated areas are elicited; later 
the rales become resonating in character and bronchial breath- 
ing develops. 

The temperature is more remitting than in ordinary broncho- 
pneumonia and the course of the disease is more protracted. 
In infants, however, it usually runs an acute course. The 
fever is not as high as in bronchopneumonia and there is less 
toxemia. Cyanosis develops in the latter stages of the disease. 

The child emaciates rapidly and anemia is pronounced. The 
cough is persistent and may be paroxysmal in character owing 
to the enlargement of the bronchial glands. Expectoration 
and hemoptysis are usually absent. The duration is variable 
and may be protracted to two or three months with apparent 
remissions in the disease. 

Diagnosis. — Bronchopneumonia running a protracted course 
with predominance of physical signs in the upper lobes and 
interscapular dulness should suggest tuberculosis. This is 
especially true of pneumonia developing after measles or whoop- 
ing cough. The same holds true of a lobar pneumonia which 
fails to undergo resolution. The probabilities are greater for 
the condition being primarily tubercular than of having become 
secondarily so. Dulness is more pronounced over a tubercular 
than over a pneumonic consolidation; the former, in fact, may 
suggest fluid and it is at times necessary to resort to the use of 
the aspiring needle to differentiate these conditions. A 
family history of tuberculosis and the tuberculous diathesis, or 
a history of exposure to a tuberculous source of infection, offer 
strong presumptive evidence. 



200 DISEASES OF CHILDREN 

Positive evidence is offered by finding the bacillus of Koch 
in the sputum. This diagnostic sign is, however, not always 
available, owing to the difficulty of obtaining sputum. A 
satisfactory method of obtaining the sputum for microscopic 
examination is suggested by Holt. A catheter is inserted 
several inches into the esophagus after a coughing spell, by 
means of which sufficient sputum can be obtained, as children 
invariably swallow their expectoration. This is a simple and per- 
fectly reliable procedure and one that should never be neglected 
in suspicious cases. A piece of gauze, held in the jaws of an 
artery clip, also answers very satisfactorily for obtaining sputum 
from the pharynx. 

Treatment. — The treatment is the same as for broncho- 
pneumonia. 

Remedies are unfortunately of little help. Iodine 3x dilution 
is the best indicated remedy, the symptoms calling for it being 
high fever, cough, rapid pulse and respirations and emaciation. 
Other remedies which may relieve some of the symptoms present 
are arsenicum, phosphorus and sulphur. The prognosis is 
always unfavorable although the disease may assume a chronic 
course or at times become apparently arrested. 

CHRONIC PULMONARY TUBERCULOSIS. 

The chronic form of pulmonary tuberculosis, in which fibrosis 
is added to the caseous process, is seldom encountered before 
the sixth year, not becoming a common disease until after 
puberty. Its course is identical with that of cases of consump- 
tion in young adults. 

A variety of lesions is found, the characteristic pathological 
changes being caseation and fibrosis in conjunction with cavity 
formation. Owing to the tendency to destruction and excavation 
of pulmonary tissue, the terms "ulcerative phthisis," and "open 
tuberculosis" are frequently employed to designate this disease. 
The coexistence of miliary granulations and areas of caseation 
and fibrosis indicates that the course has been marked by 



DISEASES OF THE RESPIRATORY TRACT 201 

remissions, as well as periods during which the pathological 
process has been active. Such a period of activity often occurs 
immediately before the death of the patient, and during its 
continuance miliary tubercles in great number may form in 
parts of the lung hitherto unaffected (Fowler). 

The seat of the earliest lesion is one of the apices, in the 
majority of cases the right. The process does not begin at the 
extreme apex of the lung, but about an inch below that point, 
and nearer the posterior and external than the anterior border, 
spreading thence backwards. The upper and posterior part of 
the lower lobe is involved often long before extensive infiltration 
or destruction of the upper lobe has taken place, and, as a rule 
before the apex of the opposite lung is attacked. Infiltration 
of the lung at this site, together with infiltration of the apex, is 
almost positive proof of the existence of tuberculous disease 
of the lungs (Fowler). 

Associated lesions usually found are bronchitis, peri-bron- 
chitis and bronchiectasis ; emphysema (compensatory) ; pulmo- 
nary collapse, the result of bronchial obstruction; edema and 
congestion at the bases ; pleurisy, usually of the chronic 
proliferating type. Lesions in other organs that may be 
encountered are tuberculous ulceration of the intestines, amyloid 
disease of the internal organs, tuberculous adenitis, meningitis 
and tuberculous arthritis. 

Females seem more prone to consumption than males. The 
ages between twenty and thirty furnish the highest percentage 
of cases, the number gradually increasing from the fifth year 
to that time. 

Certain previous diseases invite it. An attack of acute 
pleurisy often precedes the outbreak of pulmonary tuberculosis, 
or a lung impaired by a former pleurisy may become susceptible. 
Recurring attacks of bronchitis, an unresolved pneumonia, 
influenza, measles and whooping-cough are predisposing factors. 

Symptoms. — The first indications of failing health to attract 
attention to the lungs may be a gradual loss of weight. 



202 DISEASES OF CHILDREN 

Hemoptysis is a very suggestive symptom but it is not as 
frequently seen in children as in adults. Fever is usually 
present but is often unsuspected. The temperature may be 
subnormal in the morning and rise to 100° to 101° in the 
evening (rectal). Night sweats occur in the later stages when 
secondary infection has set in. The pulse is soft and rapid 
even when there is no fever. 

Physical examination reveals an emaciated frame; long, 
flat chest and superficial, feeble respiratory movements. The 
absence of the typical phthisical chest does not, however, exclude 
the possibility of pulmonary disease. When the process is 
active, the skin is dry and feverish. Commonly, enlarged 
superficial lymphatic glands can be felt in the neck and supra- 
clavicular region. The clavicles stand out prominently, as do 
also the scapulae, and the infra-clavicular region is flattened. 
Palpation reveals increased vocal fremitus in either one or both 
infra-clavicular regions; the percussion note is dull in the 
supra-clavicular region, and the area of dulness often extends 
down as far as the third rib anteriorly, occupying the inter- 
scapular space on one or both sides of the spinal column 
posteriorly. The dulness may be associated with a suggestion 
of tympanitic quality. Auscultation reveals, in the early stages, 
harsh breathing in the affected apex, associated with -Que, 
crackling rales. Broncho-vesicular breathing soon develops. 
As infiltration advances, bronchial breathing can be elicited 
in the infra-clavicular space. This can usually be demonstrated 
earliest posteriorly at a point opposite the fifth dorsal spine, 
midway between the border of the scapula and the spinous 
processes of the vertebrae ( Fowler ). As softening and excava- 
tion occur, the signs of cavity are added. 

The alimentary tract becomes deranged, and anorexia and 
diarrhea are common complications. The latter symptom, occur- 
ring at the termination of the disease, indicates intestinal 
ulceration. Vomiting may be a troublesome symptom, resulting 
either from severe coughing paroxysms or from toxemia. 



DISEASES OF THE RESPIRATORY TRACT 203 

Prognosis. — The prognosis is unfavorable, especially when 
the disease develops at the period of puberty. Cases are no 
doubt arrested but it is impossible to foretell a relapse or a 
later complication, such as meningitis. If arrest in the 
stage of infiltration can be accomplished, the prognosis is 
more favorable. The constitution and family history must 
also be taken into consideration in forming an opinion as to 
prognosis. Much also depends upon the patient's environment 
and his economic condition. If the child can be sent to a 
favorable climate and receive every possible care the outlook 
is much brighter than for the poor city dweller. 

Diagnosis. — A positive diagnosis is based upon a demonstra- 
tion of the physical signs of infiltration and destruction of 
lung-tissue described above, associated with a persistent evening 
rise of temperature. Finding the tubercle bacillus in the 
sputum clinches the diagnosis. Early in the disease, however, 
it is not always possible to find unmistakable evidence of tuber- 
culosis; and especially in children we are at a great disadvan- 
tage, owing to the difficulty of obaining sputum for microscopical 
examination. Cough and emaciation in a child with a tuber- 
culous family history, or with the history of having been exposed 
to such infection, together with slight evening pyrexia, are 
sufficient data to warrant a most thorough examinaion of the 
chest. The finding of localized subcrepitant rales at the apex 
of the lung, and prolongation of the expiratory sound in such 
a case, justifies the suspicion of tuberculosis. If sputum cannot 
be obtained a Roentgenogram should be made of the chest to 
confirm the diagnosis. 

Treatment. — In the treatment of tuberculosis prophylaxis 
is to be considered first of all. Children with a tuberculous 
family history present an inherited predisposition to pulmonary 
tuberculosis. This predisposition is not, however, confined to 
such alone, as any constitutional enfeeblement in which the 
resistance of the organism is subnormal, especially when the 
chest is underdeveloped, offers a predisposing factor. Such 



204 DISEASES OF CHILDREN 

children should be brought up in a locality where the air is 
pure and uncontaminated, and thej should be encouraged to 
lead an out-of-door life. The open-air school is a great boon to 
such children. Particular stress should be laid on the physical 
development of the chest by suitable and methodically carried 
out breathing-exercises and calisthenics; and for overcoming 
the cold-catching tendency, a cold sponge-bath, followed by 
brisk rubbing with a coarse towel, is most efficacious. 

A careful inspection of the nose and throat should be made 
to determine the presence of local pathological conditions that 
may interfere with the child's breathing. The importance of 
the early recognizing of adenoids and enlarged tonsils, and their 
prompt removal when present, cannot be overestimated. Finally, 
in order to prevent infection, the child should not be permitted 
to come in intimate contact with a consumptive. When one of 
the parents is afflicted with open tuberculosis the strictest 
precautions should be taken on his or her part not to spread 
the infection to other members of the household. 

Incipient cases are usually benefited by a change of climate. 
The requirements of a suitable climate are pure, uncontaminated 
air, equable temperature, and a maximum amount of sunshine. 
High altitude is by no means necessary; it best suits cases in 
which the disease is limited and there are no cavities. It may 
aggravate some cases by causing emphysema. Hemoptysis 
also contra-indicates a high altitude, and neurotic temperaments 
are aggravated thereby. A moderate altitude is preferable in 
most cases. The most suitable localities are the Adirondacks, 
the Southern pine regions, and the great plains bordering the 
Rocky Mountains. A location at sea-level seems better for 
chronic cases with emphysema, especially when there is nervous 
irritability, insomnia and loss of appetite. Many consumptives 
do not object to cold weather and are in fact benefited thereby. 
For these the Pocono Mountains, the Adirondacks and Colorado 
are good locations. Others do better in a warm, balmy climate 
such as the Southern Pine regions and Southern California. 



DISEASES OF THE RESPIRATORY TRACT 205 

The main advantage of climatic treatment, however, is the 
outdoor life invited thereby. No other form of treatment has 
yet given the promising results obtained in the sanatoria in 
which open-air treatment is systemically carried out, combined 
with forced feeding, rest, and judicious exercise. 

When it is impossible to send the patient away he should 
receive all the benefits of the open-air treatment at home. 

The diet is important. Patients that can be made to gain 
weight should not be despaired of. A change of climate often 
brings about a restoration of appetite when that has been on the 
wane, and may in this way alone confer great benefit. It is 
important to feed the patient as much as he can take; in fact, 
overfeeding has even proven beneficial in some instances. Milk 
and eggs are the chief foods for the tuberculous. Codliver oil 
is usually well borne by children, and is useful so long as it 
does not disturb the digestion. Even in the presence of pyrexia 
not above 100.4° F. we should not desist in our attempts at 
forced feeding. 

Special Symptoms. — Fever calls for absolute rest in bed 
or the equivalent of the same. Sponge-baths should be used once 
or twice daily to reduce the temperature. The remedies most 
useful for the febrile symptoms are baptism, chininum arsen- 
icosum, ferrum phos., and iodine. 

Cough. — A cough which occurs in the morning and is accom- 
panied by expectoration is useful, and should not be checked. 
Expectoration is materially aided by giving the patient a cup of 
hot milk, in the morning on awaking. On the other hand, a 
cough that continues during the night, causing loss of sleep, 
must be controlled (Fowler). 

Codein is the most useful opiate for controlling cough but 
its use is usually undesirable. Among homeopathic remedies 
hepar sulph. 3x trit. is one of the most useful for the teasing 
night cough of phthisis. Drosera is highly recommended by 
Hughes {Manual of Therapeutics) for cough depending upon 
increased reflex excitability. Belladonna, hyoscyamus, iodine, 



206 DISEASES OF CHILDREN 

ipecac, rumex crispus and tartar emetic should also be con- 
sidered. When profuse expectoration is present stibium iodide 
2x (Goodno), arsenicum jod., lycopodium, stannum met. and 
cole. carb. are the remedies most likely to prove useful. They 
must be carefully differentiated in order to prove helpful. 

Hemoptysis, when slight and associated with hoarsness and 
tightness across the chest calls for phosphorus. Hughes places 
phosphorus foremost when the air-passages are much implicated 
in the morbid process. 

Night-sweats are often difficult to control and are a source 
of great discomfort to the patient. They abate when the general 
condition is improved. Sometimes they are caused by too much 
bed covering and failure to carry out fresh air treatment 
to its full extent. There is therefore no advantage in using 
powerful therapeutic measures such as the administration of 
atropine to control these sweats. A cool sponge bath at bedtime 
is often beneficial. China, five drops of the tincture after meals 
and at bedtime is a good routine remedy. Silicea 6x trituration 
often acts very satisfactorily. Iron in the form of Blaud's 
pills or Ovoferrin is often helpful when the patient is anemic. 
Hughes recommends iodine for nocturnal sweats. Phosphoric 
acid 3x will do a great deal for the debility resulting from 
sweats, diarrhea and bronchorrhea. 

Gastric disorders may result from overfeeding. The best 
evidence of this is the presence of undigested food-particles 
in the stools (Fowler). When there is purely a gastric incom- 
petency, nux vomica proves of great value. A catarrhal condi- 
tion calls for such remedies as pulsatilla, hydrastis and ipecac. 
Kreosote is indicated when there is vomiting of glairy mucus, 
usually in the morning. It is a favorite remedy of the old 
school to improve the digestive function, increasing the appetite 
and checking flatulency. 

The following list of remedies, with their clinical indications, 
should be studied for a fuller knowledge of the therapeutics 
of phthisis: 



DISEASES OF THE RESPIRATORY TRACT 207 

Aconite. — Pleuritic stitches, and blood-spitting after taking 
cold. Ferrum phos. is similar, but under this remedy there is 
less circulatory excitement, and anemia and vasomotor dis- 
turbances predominate. 

Arsen. alb. — Dyspnea from exertion ; cough between 1 A. M. 
and 3 A. M. Fever-heat and chilliness intermixed. Restlessness 
and thirst for small quantities of water. There is prostration 
and emaciation; anemia and edema of ankles; terminal 
diarrhea. Mostly indicated in the pneumonic type. Arsen. 
jod. 3x trit. freshly prepared is well suited to the fibro-caseous 
form of the disease when there is profuse purulent expectora- 
tion ; emaciation ; hectic fever and prostration. Stibium iodide, 
2x trit., is highly recommended by Goodno in cases presenting 
profuse purulent expectoration. Stannum iodide has profuse 
purulent expectoration easily raised, and of sweetish taste. It 
is more useful in chronic bronchitis. 

Baptisia. — Chill in forenoon or afternoon, followed by heat 
and perspiration; general weakness and languor. Baptisia is 
one of the best remedies for the pyrexia of phthisis, and has 
been extensively used since it was first recommended by Dr. 
J. S. Mitchell. It is usually employed in the tincture and 
lower dilutions. 

Calc. carb. — "Pre-tubercular stage" in strumous subjects, 
the characteristic features being a form of indigestion associated 
with acid eructations and difficulty in assimilating fats 
(Hughes). Pale, rapidly-growing youths (phos. acid) or scrof- 
ulous children are especially benefited by this remedy. In the 
later stages it is indicated by tendency to perspire on slightest 
exertion; damp, cold feet; shortness of breath on ascending 
stairs; expectoration consisting of mucus with an admixture 
of pus which sinks in water, leaving the frothy mucus float- 
ing above. 

China. — Septic fever, consisting of a chill, followed by high 
fever and sweat, usually occurring at regular intervals. Ano- 
rexia; chronic diarrhea. (Tincture and lower dilutions.) 



208 DISEASES OF CHILDREN 

The arseniate of quinine, 3x trit., is better indicated when 
the pyrexia is more irregular, especially if arsenic symptoms 
are present. 

Ferrum phos. — Fever in the early stages, before septic infec- 
tion has set in. Hemoptysis in the early stages not dependent 
upon excavation of lung-structure. 

Hepar sulph., 3x trit., two grains every hour at night until 
cough is relieved. The cough is due to a persistent irritation 
in the larynx, not relieved by expectoration. It is excited by 
uncovering any part of the body, or by contact of body with 
cool bedclothes on first retiring. There is usually slight hoarse- 
ness, with rattling of mucus in larynx; however, expectoration 
does not relieve the symptoms. Drosera has a deep, spasmodic 
cough presenting this element of hyperesthesia, but there is not 
the free secretion present in hepar. Hyoscyamus has symp- 
toms of cough worse on lying down at night; dry, spasmodic 
and titillating in character. 

Iodine. — This remedy also presents characteristic cough 
symptoms. "Constant tickling in the windpipe and under the 
sternum, with expectoration of a transparent mucus, sometimes 
streaked with blood. Morbid hunger, soon after a meal, and 
yet loss of flesh. Dark hair and eyes" (C. G. R.). Iodine is 
one of the most useful remedies in pulmonary tuberculosis with 
active symptoms, namely, fever, cough, loss of weight. 

Kali carb. — Sharp stitches in chest ; cough worse 3 A. M. ; 
puffiness of upper eyelids and swelling of ankles. 

Lachesis. — Cough during sleep without awaking the patient; 
chilliness, followed by fever, with great talkativeness ; sensation 
of suffocation; fluttering of heart; offensive stools. 

Lycop. — Expectoration of large quantities of pus after unre- 
solved pneumonia (C. G. K.). Cough day and night, the 
expectoration tasting salty. Hectic fever, with circumscribed 
redness of cheeks, usually late in afternoon (four P. M. to 
eight P. M., aggravation of symptoms). "It suits cases of a 
chronic and passive character, and is, I think, especially useful 
when phthisis occurs in young men." — (Hughes.) 



DISEASES OF THE EESPIEATOEY TEACT 209 

Phosphorus. — Tormenting cough, often with hoarsness; 
worse toward midnight; tight and painful. There is tightness 
across upper portion of chest; inability to lie on left side. 
"Cough in the earlier stages of phthisis, with unusual implica- 
tion of the air-passages in the morbid process." — (Hughes.) 

Phosphoric acid is useful when the system has been drained 
by long-continued diarrhea or persistent night-sweats. 

Sulphur. — Delayed resolution after pneumonia; chronic 
catarrhal deposits at apices, with a few moist rales. Neuras- 
thenic individuals. Weak, gone feeling at 11 A. M., with 
craving for food or a stimulant. Morning diarrhea. 

Tuberculin (Koch) has been successfully employed in bron- 
chopneumonia, and is considered by Arnulphy capable of 
stopping the progress of incipient cases of tuberculosis of the 
lungs in a large proportion of cases {Clinique, June, 1897). 
Avian tuberculin is recommended by Cartier for suspicious 
bronchopneumonia. These nosodes have usually been given in 
the higher dilutions, either the 30th or 100th. 

EMPHYSEMA. 

Overdistention of the pulmonary air-vesicles occurs as a 
complication of most of the acute affections of the respiratory 
tract, resulting from either an interference with the function 
of a portion of the lungs (vicarious or inspiratory emphysema) , 
or from an obstruction higher up in the tract, causing dilatation 
and even rupture of air-vesicles during expiration, especially 
when this is performed in a forcible manner. The latter variety, 
or expiratory emphysema, is the commonest and most typical 
form, occurring as a complication of whooping-cough, croup, 
asthma and measles. Chronic emphysema is occasionally seen 
in children as a result of chronic bronchitis and asthma. 

Anatomically, emphysema is classified as vesicular or alveolar, 

and interstitial. In the latter form there is an escape of air 

into the connective-tissue stroma of the lungs, sometimes 

burrowing beneath the pleura and along the mediastinum into 
15 



210 DISEASES OF CHILDREN 

the subcutaneous tissue of the supra-clavicular spaces. This 
results from trauma or from spontaneous rupture of a tuber- 
culous area. 

The chronic form, or substantive emphysema, is denned by 
Delafield as a chronic interstitial inflammation of the lungs, 
in which the dilatation of the air-spaces is a secondary phe- 
nomenon. Accordingly, it is a condition whose etiology and 
pathology are analogous to that of chronic endocarditis, endar- 
teritis and nephritis. 

In acute emphysema the upper lobes are principally affected, 
and most markedly in their anterior borders. In the chronic 
form both lungs are more or less affected in their entirety, but 
seldom to the extent observed in adults. 

The symptoms of a compensatory emphysema are usually 
obscured by the original disease. Hyper-resonance, bulging of 
the supra-clavicular space during the expulsive efforts of cough- 
ing, exaggerated vesicular murmur and dyspnea are suggestive 
symptoms. 

Chronic emphysema presents the typical barrel-chest; feeble 
respiratory murmur with prolonged expiration, diminished area 
of cardiac dulness ; cyanosis, dyspnea, cough and expectoration ; 
vesiculotympanitic percussion-note. 

In the treatment of emphysema the underlying cause should 
receive principle attention. This is usually chronic bronchitis, 
asthma or cardio-renal disease. 

Such remedies as arsenicum, arsenicum iodide, aurum 
mur., ipecac, lobelia and grindelia are helpful for the res- 
piratory embarrassment. Coca and quebracho are lauded by 
Hale as the only remedies giving continuous relief. 

PLEURISY AND EMPYEMA. 

Inflammation of the pleura is rarely encountered as a 
primary disease during childhood, but it is a frequent accom- 
paniment of pneumonia. Pleurisy without exudation may 
accompany pulmonary disturbances of all kinds, and the 



DISEASES OF THE RESPIRATORY TRACT 211 

frequency with which adhesions and thickening of the pleural 
membranes are encountered in autopsies upon children points 
to the great prevalence of this condition. 

The exudative variety of pleurisy in children is generally 
purulent in nature, and occurs most frequently as a complication 
of pneumonia, or develops simultaneously with the pneumonic 
process, in which case the condition runs the clinical course of 
a pleuro-pneumonia from the onset. 

The acute infectious fevers are responsible for the develop- 
ment of some cases of pleurisy, and in older children a purely 
serous effusion may occur as a result of tuberculosis or it may 
be "rheumatic" in nature. 

The micro-organisms playing the most prominent role in the 
etiology of purulent pleurisy are the pneumococcus, the pyo- 
genic micrococci and the bacillus tuberculosis. Pneumococcus 
pleurisy is the most frequent form. It may occur simulta- 
neously with a pneumonia, or develop as a sequel to the same 
(m eta-pneumonic pleurisy). The exudate may be either sero- 
fibrinous or purulent. In the latter case the effusion is thick, 
creamy, and of a greenish color. 

Streptococcus pleurisy is more common in adults. It is 
the type of pleurisy which usually complicates influenza and 
measles. The prognosis is not so favorable as in the pneumo- 
coccus variety. The course is more prolonged and the fluid 
re-accumulates after aspiration. 

Tuberculous pleurisy may occur primarily, that is, in the 
absence of pulmonary tuberculosis ; but in these cases tubercu- 
losis of the bronchial glands is generally present. The effusion 
is sero-fibrinous at first and gradually becomes purulent. 
The course is slow and unfavorable. 

Pathology. — In the early stages of a pleurisy the membrane 
appears injected and lustreless ; later it becomes roughened and 
coated with a layer of fibrinous exudate. The extent of this 
process depends upon the severity of the attack, and it will vary 
from a delicate film of fibrin, coating only that portion of the 



212 DISEASES OF CHILDREN" 

pleura directly covering the affected portion of lung in a 
pneumonia, to a general involvement of the entire pleural 
cavity, with a thick layer of inflammatory products over the 
lung and an abundance of purulent fluid in the pleural cavity. 
In these pronounced cases the pleura appears coated with a 
yellowish-green deposit of varying thickness; the opposing 
surfaces become adherent, forming pockets filled with pus. If 
serum is poured out freely during the first stage, adhesions do 
not occur, at least not to a great extent. 

Symptoms. — A case of primary pleurisy begins with pain 
in the chest, gradually increasing fever and recurring chilly 
sensations. A painful, non-productive cough accompanies the 
condition. With the advent of the effusion the pain and cough 
become ameliorated. 

The pain is expressed by severe crying after each coughing 
paroxysm or when the child is moved ; there is also a tendency 
to avoid the affected side, and the respirations become abdominal 
in type and grunting in character. If the child be old enough to 
express its suffering, it may mislead us by referring the pain 
to the epigastric region or lower abdomen. 

With the appearance of fluid, dyspnea develops, its severity 
depending upon the amount of fluid present. 

The fever is remitting in character, seldom very high, rarely 
running above 103° F. As the acute symptoms subside the 
fever also falls but in the case of a purulent effusion there is 
a continued daily evening rise of temperature. Continued fever 
of obscure origin should suggest a sacculated empyema as a 
possible cause. Cases of pleurisy with effusion may clear up, 
suggesting that the effusion remained serous, but unfortunately 
the majority are purulent and require surgical interference. 

When pleurisy develops secondarily during the course of 
a pneumonia or some other acute infectious disease there is 
usually the characteristic pain and an accession of fever to 
call attention to this complication. Sometimes, however, it is 
impossible to determine just when the pleurisy developed, and 



DISEASES OF THE RESPIRATORY TRACT 213 

the failure of a crisis to appear in a case of pneumonia 
together with the persistence of the signs of pulmonary consol- 
idation are the first indications we may have of the associated 
pleurisy. 

The physical signs hy which pleurisy is recognized in 
children are mainly those indicating the presence of fluid in 
the thoracic cavity, as the early signs, namely, the friction-sound 
and localized pain, are not so readily elicited as in adults. By 
observing the posture of the child, however, and the fact that 
coughing induces severe pain, we are justified in suspecting the 
presence of an associated pleurisy. Conditions in which 
subcrepitant rales are present are a frequent source of error, 
they being easily mistaken for friction-sounds during infancy. 
For this reason the diagnosis of pleurisy depends upon a correct 
interpretation of painful respiration, painful cough, the charac- 
teristic onset and fever, and, still later, the demonstration of 
a pleuritic exudate. 

In the early stages of pleurisy fixation of the thorax from the 
pain is often observed in children, producing a voluntary 
scoliosis, as pointed out by Ziemssen. As a result of this 1 
abnormal position, the ribs are brought closely together on the 
affected side and the percussion note becomes dull. Under 
these circumstances, therefore, dulness may be observed before 
exudation has actually set in. 

After exudation occurs the symptoms are more characteristic. 
If the amount of fluid be considerable, there will be a noticeable 
bulging of the chest on the affected side, together with dimin- 
ished motion. When the fluid occupies the left pleural cavity 
the heart is displaced to the right; when occupying the right 
pleural cavity there is a downward displacement of the liver. 
The pleural fold is also displaced beyond the midsternal line. 

Vocal fremitus is absent over the site of the fluid, while 
the percussion-note is flat and there is increased resistance. 
These two signs are among the most important data in the 
diagnosis of effusion. Above the level of the fluid tympanitic 



214 DISEASES OF CHILDREN 

resonance is obtained when the lnngs are not entirely deprived 
of air. The line of flatness will change its direction with a 
change in the position of the patient, providing the fluid is 
not inclosed by adhesions. 

In recent cases bronchial breathing is very frequently heard 
above the line of dulness, together with Skodaic tympany to 
percussion. At the upper level of the fluid the spoken voice 
has a characteristic nasal twang (egophony). The breath 
sounds over the fluid may be bronchial in character. It is only 
in cases of large effusion that the breath sounds entirely dis- 
appear. Vocal fremitus is always diminished, however, over 
the fluid and the line of dulness is higher in the axilla than 
anteriorly or posteriorly and does not follow the outline of a 
pulmonary lobe as in pneumonia. 

In children under three years the fluid is almost invariably 
purulent, and even until puberty there is a predisposition to 
empyema. According to Baccelli a purulent exudate is less 
likely to transmit the whispered voice, but this is not 
always the case. Subcutaneous edema of the thorax on the 
affected side is a late manifestation of empyema. A positive 
diagnosis cannot, however, be made without the use of the 
aspirating needle, which is perfectly safe when used under 
proper aseptic precautions. In old cases, where the pus is too 
thick to be drawn into the needle, even this method will lead 
to error unless the negative result is properly interpreted. In 
a serous exudate, the presence of chain cocci, staphylococci, or 
the diplococcus pneumoniae, indicates that it will become 
purulent (Koplik). Tuberculous pleurisy is recognized by 
finding the tubercle bacillus in the effusion and according to 
Dieulafoy by the exclusive presence of lymphocytes and red 
blood corpuscles. In the other forms of infections pleurisy 
polynuclear and large mononuclear leucocytes predominate. 

Diagnosis. — The early diagnosis of fluid in the chest is of 
the utmost importance, particularly as the recovery of the 
patient depends largely upon the time when proper treatment 



DISEASES OF THE RESPIKATOKY TEACT 215 

has been instituted. Many difficulties may be encountered in 
establishing a diagnosis, especially as the effusion is not 
generally a large one and because it is usually secondary to 
pneumonia — metapneumonic pleurisy. The history is there- 
fore not as clear as in primary pleurisy. Again, owing to the 
marked tendency for the fluid to become encapsulated, it does 
not produce the characteristic physical signs expected of free 
fluid in the chest. The determination of the character of the 
fluid has been fully discussed above. 

The chief indications upon which the diagnosis can be made 
are absence of vocal fremitus; flat quality of the percussion-note 
and resistance; bronchial breathing and bronchophony over the 
entire affected side posteriorly and displacement of viscera. 
Koplik lays special stress upon displacement of the pleural fold 
and personally I have found it a most important physical sign. 
Xormally these folds meet in the midsternal line and when there 
is considerable fluid in either side of the chest cavity dulness 
will be found to extend beyond the median line over toward 
the well side. In smaller effusions auscultatory signs are not 
characteristic and may be misleading on account of the good 
conduction of sound in the child's chest. Dulness, with a sense 
of resistance to the finger and absence of vocal fremitus are the 
signs to be relied upon in such cases. 

Empyema should always be suspected when the temperature 
remains high for a period beyond two weeks in cases of pneu- 
monia, especially when bronchial breathing persists. 

Encapsulated fluid in unusual sites, such as the upper por- 
tion of the chest, is very difficult to differentiate from persistent 
bronchopneumonia and abscess of the lung. In the latter 
condition percussion and auscultation give practically the same 
signs, but the presence of loud, coarse pleuritic friction sounds 
are of importance as favoring the diagnosis of abscess (Holt, 
Archives of Pediatrics, Jan., 1904). 

Pericardial effusion must also be borne in mind as a possible 
condition likely to be confused with sacculated empyema. 



216 DISEASES OF CHILDREN 

Prognosis. —Serous effusions are usually absorbed readily,, 
seldom persisting over three weeks. If however pus producing 
micro-organisms gain entrance into the pleural cavity the prog- 
nosis is changed. As stated above, an empyema due to the 
pneumococcus presents the most favorable prognosis, although 
it may run a prolonged and tedious course. When the strepto- 
coccus is present open drainage offers the only chance for a 
cure. The tuberculous variety is the least favorable. Spon- 
taneous evacuation through the chest wall (usually in the 
region of the fourth or fifth rib) or through the bronchial tubes, 
by perforation into the lung parenchyma may take place in 
any case of untreated empyema. At times perforation into the 
peritoneal cavity takes place. The usual cause of death in an 
untreated empyema is the gradual exhaustion or amyloid 
degeneration accompanying prolonged suppuration, or one of 
the above mentioned accidents. 

When the fluid is removed early there is a fair chance for 
the compressed lung being restored to complete function; on 
the other hand, if the condition has been one of long standing, 
dense bands of adhesions are formed to such an extent that the 
lungs become crippled and the thorax deformed. 

Treatment. — Hot applications are helpful in the early 
stages. Strapping the chest is not advisable in cases of second- 
ary pleurisy. Fluid which is present in considerable amount 
should be promptly evacuated if absorption is not progressing 
rapidly ; under no circumstances should accumulations of fluid 
be allowed to remain in the chest for a period exceeding two 
weeks, unless decided improvement is noted daily. If the fluid 
is purulent it should be withdrawn every second or third day 
during the acute stage of the disease. Radical surgical treat- 
ment should not be instituted until the associated pneumonia 
has run its course and the toxemia begins to subside. The 
operation of choice in infants is simple incision in an inter- 
costal space with the introduction of a drainage tube while 
in older children the resection of a piece of rib is perfectly 
safe and gives the best results. 



DISEASES OF THE RESPIRATORY TRACT 217 

Diagnostic puncture of the chest is most satisfactorily per- 
formed with a Luer syringe. The usual site of puncture is the 
sixth or seventh interspace in the axillary line or the eighth 
interspace posteriorly. The needle should not be inserted too 
close to the spine, and should he directed toward the upper 
border of the rib rather than to its lower, on account of the 
intercostal arteries. Koplik insists on puncturing at the site 
indicating fluid, as elicited by flatness and absence of vocal 
fremitus, rather than at some point of election ; when the empy- 
ema is localized this rule is absolutely essential to follow. 

Remedies. — Aconite, arnica, belladonna, bryonia, kali 
carb., rhus tox., and scilla are indicated in the early stage of 
pleurisy. 

When exudation is abundant, apis, cantharis, iodium and 
Sulphur are most frequently indicated. 

The clearing up of a purulent exudate, after proper surgical 
measures have been instituted, is helped by hepar sulphur. 

Aeon. — Sharp, stitching pain in side; high fever, restless- 
ness and chills; after exposure to cold, dry winds or checked 
perspiration. 

Apis — Pleuritic effusion; scanty urine. 

Arnica. — Traumatic cases; hemorrhagic effusion. 

Arsenicum. — Profuse serous effusion; dyspnea; cachexia; 
prostration; empyema. The iodide of arsenic is well suited 
to tuberculous cases, as is also iodium. 

Bellad. — Cerebral symptoms; complicating the infectious 
fevers or exanthemata. 

Bryonia. — Early stage of all pleurisies, and in dry pleu- 
risy frequently to the end. Sulphur is needed in the latter 
cases to complete the cure. Sharp, stitching pains, aggravated 
by motion and deep breathing ; friction sounds and local tender- 
ness. 

Canth. — Profuse serous exudation; frequent cough; dysp- 
nea; palpitation; profuse sweats; great weakness; tendency 
to syncope; scanty and albuminous urine. — (E. Eaivre.) 



218 DISEASES OF CHILDREN 

Colchicum. — Rheujmatic diathesis; sour-smelling sweats; 
scanty red, turbid urine, with abundant uric acid and some 
albumin. 

Hepar. — After drainage has been established. Profuse, 
purulent discharge from pleural cavity. 

Kali carb. — Violent stitching pains, especially on left side, 
worse in early morning (after fresh adhesions have formed 
during sleep), accompanied by dry cough and palpitation of 
the heart. When bryonia fails to give relief. 

Iodium. — Tuberculous pleurisy. 

Mercurius. — Syphilitic or rheumatic diathesis; pains per- 
sisting after the fever subsides; constant chilliness, with tend- 
ency to sweat; gastro-intestinal catarrh; perihepatitis. Merc, 
corr. is useful in pleuritic effusions accompanying parenchyma- 
tous nephritis. 

Rhus tox. — Acute rheumatic cases, after exposure to wet. 
General aching and prostration; continued fever with great 
restlessness ; typhoid state. 

Scilla. — Sharp stitching pains in side with broncho-pneu- 
monia ; prostration ; cardiac weakness. Cannot lie on left side. 

Sulphur. — Stage of effusion in primary serous pleurisy. 
Sulphur is the best remedy to hasten the absorption of a non- 
purulent pleural effusion. 



CHAPTER X. 

DISEASES OF THE HEART AND ITS MEMBRANES. 

Organic heart disease in childhood may be either congenital 
or acquired. Congenital affections result from fetal endo- 
carditis or from developmental defects. Acquired heart disease 
in childhood is the result of infection (rheumatic) and presents 
the same pathological processes observed in adults with the 
exception that the degenerative and luetic changes affecting 
especially the aortic valves and the bloodvessels in adult life 
are not encountered in childhood. Functional disorders are 
rare and of little clinical significance. Sinus irregularity and 
neurotic pains or palpitation are the chief functional disturb- 
ances encountered. 

The heart is relatively larger in infancy than in later life, 
but it does not increase in size proportionally with the growth 
of the child, developing only slightly during the first five years 
of childhood (Barthez and Eilliet). It occupies a higher and 
more horizontal position than in the adult, and for this reason 
cardiac dulness extends relatively further both to the right and 
to the left of the sternum. At the sixth year dulness may still 
extend beyond the right border of the sternum, and the apex 
is generally found outside of the left nipple-line up to the fourth 
year. The apex may be in the fourth intercostal space until 
the sixth or seventh year. After the seventh year, however, it 
should be located within the left nipple-line and in the fifth 
intercostal space. It is important to remember that the nipple 
is not an absolutely fixed point, and that it may be found in the 
third or fourth intercostal space or over the fourth rib. Most 
fiequently it is situated over the fourth rib, somewhat nearer 
the median than to the mid-axillary line. 

In young children deep cardiac dulness extends beyond the 
left mammary line and on the right it may reach the parasternal 



220 DISEASES OF CHILDREN 

line. After the seventh year the position of the apex and the 
area of deep dulness are relatively the same as in the adult. 

Owing to the yielding character of the sternum and of the 
costal cartilages, enlargement of the heart may cause a decided 
bulging of the front of the thorax up to the third year. This 
is usually seen in congenital heart disease. The third piece of 
the sternum may be misplaced at even a later period, as Rotch 
pointed out, owing to the fact that it is ossified later than the 
upper portions. Pericardial effusion will cause bulging in 
the regions of the heart at any period of childhood. The fig- 
ures obtained by measuring the distance from the midsternal 
line to the outer edge of the apex furnish valuable data for esti- 
mating the extent of cardiac enlargement, and are also an im- 
portant matter of record for future reference. From the exam- 
ination of a large number of normal children at different ages 
I have obtained the following data: Distance from the mid- 
sternal line to the outer edge of the apex in the newborn, 4.5 
cm. to 5 cm. By the tenth year it is 7.5 cm., or 3 inches, in 
the average case. In a male child from one to two years old 
it is from 5.5 to 6 cm., usually a trifle less in females. From 
the fourth to the sixth year it averages 6 to 6.5 cm. and may 
reach 7 cm. by the seventh year. In severe forms of valvular 
heart disease it is not uncommon to find the left border reach- 
ing from 11 to 12 dm. from the midsternal line. The yearly 
gain in the distance of the apex from the median line seems 
trifling and does not appear to correspond with the increase in 
the size of the heart, but it must be remembered that the heart 
is relatively large in early childhood and also that it assumes 
a more vertical position with the fuller development of the 
child. 

The pulse is soft and dicrotic in character during childhood ; 
it is rapid and irregular in infants. Its rate is about 130 at 
birth; 120 at the end of the first year, and usually remains 
about 100 up to the fifth year. The blood pressure is normally 
low. A rapid pulse may be of purely nervous origin and is 



DISEASES OF THE HEART AND ITS MEMBRANES 221 

therefore not a trustworthy sign of cardiac weakness. Arhy- 
thmia is also of little significance as it is usually of the type 
of sinus irregularity. A slow pulse however is more significant. 
This is characteristically seen in diphtheritic myocarditis. 

Heart sounds. — The first sound of the heart obtained over 
the apex is the loudest and has the characteristic booming qual- 
ity heard in the adult. During infancy, however, the muscu- 
lar element is lacking and the first sound is short and more 
distinctly valvular in quality. Throughout the entire period 
of childhood the pulmonary second sound predominates over 
the aortic second sound. In valvular heart disease the pulmon- 
ary second sound becomes distinctly accentuated. Heart mur- 
murs are common in childhood and it is important to determine 
whether they signify an organic lesion or whether they are 
functional or purely accidental. 

Anemic or Functional Murmurs may be heard in a severe 
case of anemia at any time of life. They are most commonly 
encountered in older children suffering with chlorosis. They 
are heard loudest at the pulmonary valve, and are systolic. 
There is no heaving impulse, accentuated second sound, or ex- 
tension of the apex-beat beyond the mammillary line. The pul- 
monary area is so frequently the seat of murmurs that Balfour 
has referred to it as the area of ausculatory romance. 

C ardio-pulmonary murmurs (Hochsinger) are produced by 
the transmission of the contractions of the heart and its move- 
ments to the lungs. These murmurs are systolic, and are 
differentiated from anemic murmurs by their definite relation 
to the respiratory function, being increased during forced and 
suspended by a cessation of respiration. They are common in 
children with deformed chests, due to rickets or Pott's disease, 
and are best heard over the precordial region. 

The endocardial systolic murmur is an indication of a leakage 
at the mitral valve. In the active stage of the endocarditis there 
is fever, evidence of heart weakness, increase in the area of 
cardiac dulness and accentuation of the pulmonary second 



222 DISEASES OF CHILDREN 

sound. After the endocarditis has subsided, mitral regurgita- 
tion may remain as a permanent defect. 

Other murmurs which may be heard in chronic valvular 
disease are the presystolic, which may also be felt as a thrill in 
the precordial region. The presystolic murmur is fugitive in 
character and may only be heard when the patient has been 
active, disappearing on resting. 

CONGENITAL DISEASES AND DEFORMITIES. 

Congenital defects such as nonclosure of the foramen ovale 
or a patent ductus arteriosus may exist without producing 
clinical symptoms. A lesion of the pulmonary artery, however, 
produces unmistakable signs of circulatory obstruction. This 
lesion is seldom found existing alone, for the increased intra- 
venticular pressure which results from the pulmonary stenosis 
leads to a nonclosure of the auricular and ventricular septa or 
to a dilatation and persistence of the ductus arteriosus. Clinic- 
ally, therefore, a combination of a lesion and a defect is the 
common finding. In Holt's series of 242 cases the following 
combinations were the ones most frequently encountered, in the 
order given : Pulmonic stenosis with defective auricular septum, 
the three lesions associated, or the first two with a patent ductus 
arteriosus. 

Inflammation of the endocardium in the fetus is of the 
chronic or sclerotic variety, verrucose endocarditis being very 
rare (Osier). Small, nodular bodies, the remains of fetal 
structure (Bernays), and small, rounded, bead-like bodies of 
a deep purple color, which are the remains of a hemorrhage 
(Osier) have frequently been mistaken as evidences of endocar- 
ditis, leading to a misconception as to the prevalence of this 
affection. The belief in fetal endocarditis has been abandoned 
by some of the more recent investigators in this field and even 
pulmonary stenosis is classed by them as a developmental defect. 

Defects of the ventricular septum, is most frequently associ- 
ated with pulmonic stenosis or defect of the auricular septum. 



DISEASES OF THE HEART AND ITS MEMBEANES 223 

The defect is most frequently found in the anterior muscular 
portion of the septum (Kokitansky). If compensatory hyper- 
trophy of the right ventricle supervenes, no apparent symptoms 
may be present. 

Patency of the foramen ovale may exist without any evidence 
of cardiac disease. When, however, other anomalies increasing 
the pressure in the right auricle co-exist, a mixing of venous 
and arterial blood takes place, with resulting cyanosis. 

Stenosis of the pulmonary artery is the most important 
congenital affection, the above mentioned conditions in the 
majority of instances being the direct results of the pulmonary 
stenosis. The symptoms depend upon the amount of constriction 
at the pulmonary orifice. The infant may die shortly after 
birth with intense cyanosis and asphyxia, or it may grow up to 
adult life, with, however, defective blood aeration; cyanosis, 
usually manifest when crying or after physical exertion; cold- 
ness of the extremities, clubbing of the finger-nails, and mental 
and physical backwardness. Uncomplicated, and therefore 
uncompensated, pulmonary stenosis usually leads to death in 
early infancy. 

Patent ductus arteriosus does not necessarily produce symp- 
toms. When, however, the ductus is dilated as a result of an 
associated lesion we may suspect this condition from the presence 
of a thrill at the base of the heart and the transmission of a 
murmur into the carotids. It also induces hypertrophy. 

Abnormalities in the origin of the great vessels are rare, and 
lead to early death or make extra-uterine life impossible, unless 
there is an open foramen ovale or a communication between the 
pulmonary veins and the right side of the heart. 

Tricuspid insufficiency and stenosis are grave defects, re- 
sulting from endocarditis. There may be complete artesia of 
the orifice, in which case a degree of circulation is maintained 
through an incomplete ventricular septum. The right heart 
becomes dilated and hypertrophied ; there is cyanosis and 
tendency to venous hemorrhages. 



224 DISEASES OF CHILDREN 

Affections of the left heart are exceedingly rare and usually 
masked by other defects. 

Symptoms. — The most characteristic symptom of congenital 
heart disease, and the one which, as a rule, first calls our 
attention to the fact that the infant is afflicted with a cardiac 
defect is cyanosis. The baby is a "blue baby," either showing 
some degree of cyanosis continuously, especially at the finger 
tips, the lip and toes, or it becomes cyanosed when crying. 
Cyanosis is usually detected soon after birth; sometimes it is 
latent and first observed during an attack of bronchitis or 
during a severe crying spell. 

Cyanosis is absent in defective ventricular septum and may 
be absent in cases with patent ductus arteriosus. Well defined 
cyanosis always indicates pulmonary stenosis. When cyanosis 
is absent or only present to a slight degree congenital heart 
disease may not be suspected until a thrill or murmur is detected 
during a routine examination of the infant. The remote 
effects of congenital heart disease are a stunting of the growth 
of the child; clubbing of the finger tips and toes; dyspnea 
on exertion; susceptibility to pulmonary affections. Cases 
without cyanosis may attain adult life and enjoy apparently 
good health while those with marked cyanosis suffer with 
malnutrition and die in early childhood. Intermediate cases 
present about the same problems as the child with acquired 
heart disease. 

The diagnosis rests upon a recognition of the above mentioned 
symptoms, together with the associated physical signs. 

Stenosis of the pulmonary artery presents hypertrophied 
right heart; loud systolic murmur over the second and third 
costal cartilages to the left of the sternum, not transmitted into 
the carotids, and a thrill. The pulmonary second sound is 
weakened. When these signs are present in an infant past 
its first year it may be assumed that the foramen ovale has 
remained patent or there is an associated septum defect. When 
there is a loud, buzzing murmur transmitted into the carotids 



DISEASES OF THE HEART AND ITS MEMBEANES 225 

and subclavians, together with accentuated pulmonary second 
sound and hypertrophy of both ventricles, there is probably 
associated an open ductus arteriosus (Hochsinger, Auscultation 
des Kindlichert Herzens). 

Patency of the ductus arteriosus leads to hypertrophy of 
the right ventricle and dilatation of the pulmonary artery. The 
characteristic murmur is a continuous humming sound trans- 
mitted into the carotids. 

The following table is given as an aid in the classification 
and differential diagnosis of the different forms of congenital 
heart disease: 

1. Cases with cyanosis: Pulmonary stenosis. 

2. Cases without cyanosis: Patent foramen ovale; defect 
of ventricular septum; open ductus arteriosus. 

3. Cases with hypertrophy: Pulmonary stenosis, right 
ventricle; patent ductus arteriosus, right ventricle and pul- 
monary artery; defect of ventricular septum, both ventricles. 

4. Cases without hypertrophy: Open foramen ovale. 
Murmurs. 

Systolic murmur and thrill over pulmonary area — pulmon- 
ary stenosis. 

Systolic murmur at apex, not transmitted to carotids — 
defect of ventricular septum. 

Systolic or humming-top murmur, transmitted into carotids 
— open ductus arteriosus alone. 

Systolic murmur transmitted to carotids with thrill, cyanosis 
and hypertrophy — Pulmonary stenosis with associated open 
ductus arteriosus. 

The treatment is largely constitutional. The feeding of 
these cases usually presents difficulties and is to be carried out 
along the lines as suggested for the feeding of difficult cases. 
Protection of the child against exposure and against the acute 
infectious diseases is imperative. Acute affections of the res- 
piratory tract are especially to be feared. Attacks of cyanosis 
16 



226 DISEASES OF CHILDREN 

or threatened cardiac failure and dyspnea will call for stimula- 
tion with either aromatic spirits of ammonia or brandy. 

Cases without cyanosis present a better prognosis than those 
in whom this symptom is present. They should not be restricted 
too much in their play as a certain amount of exercise is 
beneficial to them. Many cases with a congenital lesion, notably 
an open ductus arteriosus, attain adult life and are but slightly 
handicapped by their affliction. 

On general lines aconite, arsenicum, camphor, cuprum, 
digitalis, glonoin, lachesis, rhus tox. and veratrum viride are 
to be considered, their symptomatology covering the condi- 
tions met with in these cases, namely, hypertrophy, dyspnea, 
excessive heart-action, cyanosis, etc. 

PERICARDITIS. 

Pericarditis, or inflammation of the pericardium, may be 
either acute or chronic and primary or secondary. Acute peri- 
carditis in infancy usually occurs as a complication of pneu- 
monia, notably pleuro-pneumonia. In older children it is most 
frequently a complication of rheumatic fever, in fact, involve- 
ment of the pericardium is to be anticipated in all severe cases 
of rheumatic carditis. Acute pericarditis may also occur as a 
complication of scarlet fever, focal infection and sepsis. It may 
occur from traumatism and from the extension of the infection 
from the lung or pleura. A chronic, adhesive type of peri- 
carditis which is probably tubercular in origin is occasionally 
encounterd in which there is associated involvement of other 
serous membranes. The name "polyserositis, or multiple sero- 
sitis" is given to this distinct clinical form of pericarditis. 

The pathological changes in pericarditis are the same as are 
observed in inflammation of other serous membranes. In the 
dry form, there is merely a loss of the normal gloss and smooth- 
ness of the membrane covering the heart and lining the peri- 
cardial sac together with the deposit of fibrinous exudate. The 
process usually begins at the base of the heart where the inflam- 



DISEASES OF THE HEART AND ITS MEMBRANES 227 

matory reaction is most marked and where the first friction 
sonnds are generally heard. In the serous variety an abundance 
of serous fluid is poured out which distends the pericardial sac 
causing a bulging in the cardiac area and a muffling of the heart 
sounds. The fluid usually absorbs spontaneously, leaving, how- 
ever ; a roughened membrane covered with exudate with result- 
ing adhesions between the heart and pericardium. Adhesions 
and obliteration of the pericardial sac are however more likely 
to occur in the dry, or fibrinous than in the serous form. 

Purulent pericarditis does not undergo spontaneous absorp- 
tion and presents a most unfavorable prognosis. It is a frequent 
complication of fatal cases of pleuro-pneumonia and of sepsis. 

Chronic pericarditis results either from recurring attacks 
of rheumatic pericarditis or it is tubercular in origin. The 
tubercular cases rarely show tubercles upon the pericardial sur- 
face; the pathological changes observed are similar to those 
seen in chronic, proliferating pleurisy. There is usually in- 
volvement of the tissues of the mediastinum causing dulness 
in the upper sternal region. Chronic mediastinitis, either tu- 
bercular or rheumatic, causes physical signs often mistaken for 
aortic disease. Chronic rheumatic pericarditis is almost invari- 
ably associated with valvular heart disease while the tubercular 
form complicates pulmonary tuberculosis or is one of the lesions 
of a polyserositis. 

Symptoms. — Pericarditis is rarely recognized in infants, 
being usually a complication of such a condition as pleuro- 
pneumonia or sepsis. 

If the child is old enough to complain of pain in the region 
of the heart, which may also be referred to as radiating to the 
left shoulder or epigastrium, or as occurring alone in these 
locations, a careful physical examination may reveal local tend- 
erness and possibly cardiac friction-sounds over the base of 
the heart. If friction-sounds are elicited, they will be heard as 
rubbing or crackling sounds synchronous with the heart's action 
and independent of respiration. They are loudest under the 



228 DISEASES OF CHILDREN 

fourth rib to the left of the sternum, and may simulate a, mitral 
regurgitation murmur. The loud friction-sound disappears 
when fluid accumulates in the pericardial sac but there is 
usually a persistence of some friction at the base, probably 
due to an associated mediastinitis. 

With the appearance of the effusion the pulse becomes feeble 
and irregular. Oppression, dyspnea and cyanosis develop with 
the outpouring of sufficient fluid to embarrass the heart's action ; 
and eventually convulsions, and in older children delirium and 
coma, close the scene in fatal cases. A rapid outpouring of 
serum into the pericardium may produce sudden death. We 
sometimes see this occur during an attack of rheumatic fever 
and in pneumonia. 

Bulging of the precordial region, increased area of cardiac 
dulness, and muffling of the heart sounds are the characteristic 
physical signs of pericardial effusion. The area of dulness 
is not triangular as in adults, and the heart, with its distended 
sack, retains its normal position, simply enlarging. Enlarge- 
ment is more pronounced to the left. Unless dulness reaches 
up to the second interspace on the right side, it is more likely 
due to dilatation of the right ventricle than to fluid (Koplik). 
The percussion note is flat and resistent. 

Adhesions are to be suspected when there is a displacement 
of the apex not due to marked hypertrophy, or cardiac dilata- 
tion and retraction of the intercostal space during systole. The 
mere retraction of the apex region during systole is by no means 
diagnostic of pericardial adhesions. When, however, this is 
associated with retraction of a considerable area of the thorax 
during systole, which rapidly returns to normal during diastole, 
we have strong evidence of the same (Gerhardt, Lehrbuch 
der Auskultation u. Percussion). Perhaps the most conclusive 
sign is that pointed out by Broadbent, namely, retraction of 
the lower intercostal spaces posteriorly, due to tugging on the 
adherent diaphragm. Broadbent's sign is conclusive evidence 
of extensive pericardial adhesions but is rarely encountered. 



DISEASES OF THE HEART AND ITS MEMBRANES 229 

The only definite physical sign upon which a positive diag- 
nosis can be made is the fixed position of the heart irrespective 
of the patient. This is demonstrated by noting the position 
of the apex beat and deep cardiac dulness with the patient 
standing, recumbent and lying on the right side. Together with 
this sign there is progressive asystole rebellions to any form 
of treatment (Apert, Maladies des Enfants). When systolic 
retraction in the precordial region is associated with diffuse 
diastolic collapse of the jugular veins the probabilities of an 
adherent pericardium are increased. 

The prognosis of pericarditis is always grave, particularly 
when complicating pneumonia and scarlet fever. A serous, 
rheumatic pericarditis usually undergoes spontaneous absorp- 
tion but the danger of pericardial adhesions and recurrence 
must always be considered. The prognosis of adherent peri- 
cardium is bad because of the secondary changes in the heart 
muscle which result therefrom. 

Treatment. — Absolute rest in bed is imperative until every 
evidence of fluid or cardiac weakness has disappeared. With 
large effusions aspiration may become necessary; purulent peri- 
carditis requires surgical treatment. 

Aeon. — Chilliness; hard, bounding pulse; sharp pain in 
region of heart; great restlessness, dyspnea and nervous excite- 
ment. 

Arsen. — Great anguish and oppression; constantly changing 
position; cyanosis; thirst; in consequence of repelled exan- 
thems, or in connection with pneumonia ; stage of effusion. 

Bryonia. — This remedy follows well after aconite, and is 
most applicable during the stage of effusion, although it seldom 
absorbs the exudate completely. Sulphur is a most valuable 
remedy for this purpose, especially when the case becomes 
protracted. 

Cactus grand. — Sensation of constriction about the heart, 
as if a strong hand were grasping it. There may also be a 
sense of deep-seated soreness in the precordium, with dysp- 
nea; attacks of suffocation; fainting, small, irregular pulse. 



230 DISEASES OF CHILDREN 

Digitalis. — Copious serous effusion; small, irregular, rapid 
pulse ; diarrhea and vomiting. 

Iodium. — Complicating croupous pneumonia. Violent pal- 
pitation and oppression from slightest motion; must lie per- 
fectly quiet on back. 

Spigelia. — After aconite, when the friction sound becomes 
audible. Sharp, stitching pains in chest. Spigelia is a most 
efficient remedy for the painful stage. 

ENDOCARDITIS; VALVULAR HEART DISEASE. 

Acute endocarditis in childhood is most frequently a compli- 
cation of rheumatism and may occur as the primary manifes- 
tation of this affection. Joint symptoms are less characteristic 
of rheumatism in children than in adults but endocarditis is 
more likely to develop as a complication of this disease in 
childhood. Chorea, which is one of the clinical manifestations 
of rheumatism in childhood, is also frequently complicated with 
endocarditis. Every case of rheumatism, therefore, however 
mild the joint manifestation may be, and every case of chorea, 
should be watched for signs of endocarditis. Endocarditis may 
also occur as a complication of tonsillitis, scarlet fever, pneu- 
monia, gonorrhea and septicemia. There is a special type of 
endocarditis resulting from a general blood infection with the 
streptococcus mitis which is described as septic endocarditis. 
This form of endocarditis is far less common than the rheumatic 
variety. The pathological process in bacterial endocarditis is 
a destructive one (ulcerative endocarditis) and the prognosis 
is most unfavorable. 

In simple, or verrucose endocarditis the valves are covered 
with inflammatory excresences — endocardial vegetations. These 
result from the deposit of fibrin and leucocytes upon the necrotic 
areas which are produced in the endocardium by the bacteria 
and their toxins. The valves become thickened, shortened and 
distorted and consequently incompetent. The mitral valve is 
the one chiefly involved. In cases of bacterial, or septic endo- 



DISEASES OF THE HEART AND ITS MEMBEANES 231 

carditis, both the mitral and aortic valves are usually affected. 
Portions of the valvular deposit may become detached and swept 
into the general circulation, producing emboli at distant points. 

Chronic endocarditis, or chronic valvular heart disease is a 
sequel of acute endocarditis. In children there is a notable 
tendency to recurrence of the endocardial inflammation, each 
new attack increasing the disability of the already damaged 
valves and thus adding to the strain on the heart muscle. The 
commonest valvular defect resulting from these pathological 
changes is mitral regurgitation, although mitral stenosis and 
aortic regurgitation may also be encountered. 

Symptoms. — An irregular continued fever in childhood, at 
times hardly perceptible, often disappearing after rest in bed 
and accompanied by malaise, pallor and moderate anemia should 
always arouse the suspicion of a rheumatic infection. In the 
absence of active throat manifestations or of joint involvement 
this febrile disturbance should at once lead us to suspect the 
presence of a low grade endocarditis. Tuberculosis, of course, 
must be excluded as a possible cause for such a rise of temper- 
ature. At the onset of endocarditis repeated examination of 
the heart will reveal a weakening and blurring of the first sound 
at the apex with the gradual development of a blowing murmur. 
With the establishment of the murmur the area of deep cardiac 
dulness increases and the pulmonary second sound becomes 
accentuated. These signs are found in the great majority of 
cases because the mitral valve is the one most frequently 
attacked by rheumatic endocarditis and a mitral insufficiency 
is the commonest lesion resulting therefrom. In the early 
stages the murmur may be heard more distinctly just over the 
area of the auriculoventricular orifice than at the apex, and 
owing to the adaptability of the child's heart to any extra strain 
the pulmonary second sound may remain unaltered for some 
time. The murmur just described may also occur in the myo- 
carditis associated with diphtheria and other acute infectious 
diseases. However, in such cases, it is only of temporary 



232 DISEASES OF CHILDREN 

duration and disappears during convalescence from these dis- 
eases after the heart muscle has regained its tone. 

Mitral stenosis may develop in conjunction with insufficiency 
or exist alone. The first physical sign to be noted is a faint 
murmur occurring in early diastole. The cause of this murmur 
is the flow of the blood current over the roughened edges of 
the auriculo ventricular orifice during the early part of diastole. 
Later, as contraction and distortion of the orifice develop the 
auricle is called upon to force the blood through the stenosed 
orifice, and as a result of this exaggerated auricular contraction 
in late diastole we now hear the loud rumbling presystolic 
murmur accompanied by a palpable thrill, a sharp snapping first 
sound and usually reduplication of the second sound. The last 
results from the high tension in the pulmonary artery. 

Aortic disease is rare in childhood and is indicative of a 
severe progressive type of endocarditis (subacute bacterial 
endocarditis). At first a systolic murmur over the aortic area 
transmitted into the carotid and accompanied by a weakening 
of the aortic second sound is heard. The cardiac enlargement 
progresses and the patient's discomfort is much increased. This 
is followed by throbbing carotids, collapsing pulse and total 
obliteration of the aortic second sound showing that the valves 
have become incompetent. In the general cardiac turmoil an 
aortic diastolic sound is difficult to detect and this is unnecessary 
for the diagnosis. 

The severe cases of acute endocarditis which one is apt to 
encounter usually present the following history: A child from 
five to ten years is attacked with sore throat followed by ar- 
thritic manifestations of moderate severity. There is slight 
fever. Suddenly the temperature rises, the patient complains of 
pain in the cardiac region and epigastrium ; there is cough and 
shortness of breath. Examination of the heart reveals increase 
in the area of cardiac dulness, a loud murmur at the apex and 
possibly friction sounds near the sternum. Circulatory failure 
progresses until a fatal termination sets in. The duration of 
the entire illness may be but a few weeks. 



DISEASES OF THE HEART AND ITS MEMBRANES 233 

More common, however, is the recurring form and this fur- 
nishes the cases we see most frequently in the hospital wards. 
The child is brought to the hospital for an attack of rheumatism, 
chorea, or for shortness of breath, and an old valvular lesion is 
discovered. Inquiry into the past history of the case discloses 
the fact that the child has had a previous attack of rheumatism 
or chorea, or perhaps such vague symptoms as sore throat and 
growing pains. The rheumatism or chorea subsides, but the 
fever continues, due to the presence of endocarditis. After 
several weeks in bed the process subsides, the heart muscle 
regains its tone and the breathing and pulse improve. The child 
is now dismissed from the hospital, but we anticipate his return 
in the near future in a worse condition than on the previous 
admission. Fully half of these cases succumb to their malady 
before puberty. 

Prognosis. — The literature upon heart disease in childhood 
agrees more or less in giving to the prognosis an unfavorable 
aspect. It is, however, difficult to get a clear conception of this 
important question because of the lack of definite statements 
that are to be found. The statistics given by Dunn (American 
Journal Diseases of Children, August, 1913), have furnished 
much valuable information in this direction. 

In the first place, according to Dunn's figures, the ultimate 
disability following rheumatic heart disease acquired in early 
childhood is not nearly so great as that following endocarditis 
occurring in late childhood. Thus, out of a series of 88 cases 
in young adults with evidence of former endocarditis only two 
showed great disability and in these the attack occurred in the 
twelfth and thirteenth year. The younger the child, therefore, 
when the endocarditis occurs, the better the chance for the future 
as far as permanent after effects are concerned. Compensation 
is established not only by means of a mechanical hypertrophy 
of the heart but also through mutual adaptation between the 
heart and the organism. 

These figures, however, should not lead us to overlook the 



234 DISEASES OF CHILDREN 

real and more important side of the question, namely, that it 
is only the mild, non-recurring cases that live beyond puberty 
and make up this class of young adults with a non-serious well 
compensated valvular lesion. The immediate mortality out of 
a series of 261 of Dunn's cases was 20 per cent. Out of the 
remaining 209 cases 50 per cent died during the subsequent 
ten years. 

From these figures, then, it may be seen that the majority of 
children attacked with endocarditis do not live beyond puberty. 
One of the chief reasons for this unfortunate outcome is the 
liability to recurrence which is so strong in rheumatic fever, 
being noted in fully 80 per cent of cases. With these recur- 
rences increase in the existing danger to the heart occurs. 
Another factor, already mentioned, is the tendency to a general 
carditis, the process not remaining limited to the lining of the 
heart as in the adult. We must also take into consideration the 
unusual demands made upon the heart of the young growing 
organism in order to maintain an adequate circulation of 
the blood. 

Even in spite of these demands and in the presence of a 
badly damaged valve, the child's heart seldom fails and heart 
failure in childhood usually results from an acute process or 
from an acute exacerbation of an old condition. During such 
an attack, fever, cough, shortness of breath and pain are the 
prominent symptoms and the child often dies before edema of 
the extremities and enlargement of the liver develop. Reinfec- 
tion and not strain, as in the case of adults, leads to the final 
breakdown. It is perhaps chiefly for this reason that remedial 
measures that so frequently relieve the symptoms of decom- 
pensation in the adult are futile in these crises in childhood. 

The worst prognosis may be anticipated when pericarditis 
occurs as a complication. A progressive asystole, rebellious to 
any form of treatment, may be looked upon as the chief clinical 
symptom of an adherent pericardium (Apert, Maladies des 
Enfants). Acute pericarditis with effusion gives a high immed- 



DISEASES OF THE HEART AND ITS MEMBRANES 235 

iate mortality (31 per cent, Dunn). An adherent pericardium 
leads to progressive heart failure; ascites and anasarca may 
become prominent features and the case assume the clinical type 
of pseudo-cirrhosis of the liver. 

To recapitulate, the child's heart if not too seriously involved 
and if not handicapped by recurring infections may hyper- 
trophy in a most favorable manner and adapt itself to a valvular 
defect; in fact, "the entire organism adapts itself to the new 
condition arising in the circulatory apparatus" (Feer, Kinder- 
heilkunde). Unfortunately this occurs in the minority of 
instances. We occasionally meet such cases in our practice and 
follow them through puberty to early adult life, but always 
with misgivings. 

A fortunate circumstance in connection with rheumatic fever 
is that after adult life is reached there is less tendency to endo- 
carditis than in childhood. 

The chief reasons for the unfavorable outlook in rheumatic 
heart disease in childhood is the tendency to recur and the fre- 
quency with which myocarditis and pericarditis are associated 
with the endocarditis. 

Cardiac insufficiency in children results from infection or 
reinfection, and not from strain, as does the ruptured com- 
pensation in adults. The particular valve involved is of no 
special prognostic significance. 

Involvement of the aortic valve is grave, for the reason that 
it is practically never affected alone, but only in conjunction 
with the mitral valve in the more violent types of endocar- 
ditis. Many of these cases assume the type of "septic 
endocarditis." 

Diagnosis. — Cases of valvular heart disease may exist for 
a long time unrecognized, and be first discovered during a 
routine examination of the chest. This is especially so when 
the endocarditis has developed insidiously during an attack 
of chorea or in conjunction with mild, atypical attacks of 
rheumatism. These children are brought to the clinic for 



236 DISEASES OF CHILDREN 

vague symptoms such as pallor, listlessness, (poor appetite, 
shortness of breath, and loss of weight. Often they run a 
slight temperature, suggestive of tuberculosis. Endocarditis 
may be the primary manifestations of the rheumatic cycle, 
arthritic manifestations and chorea appearing later on. 

Again, a child may be brought to the physician on account 
of pain referred to the epigastric region, and the examination 
reveal a pericarditis. From these facts, the importance of 
routine examination of the heart becomes apparent. 

A murmur alone is not sufficient evidence upon which to 
make the diagnosis of endocarditis. One must demonstrate 
the presence of enlargement of the heart as well. In fact, in 
acute myocarditis of diphtheria and pneumonia, and in the 
dilatation of whooping-cough, increase in the area of deep 
cardiac dulness, together with a systolic apical murmur, is 
frequently encountered. These physical signs, however, are 
only of temporary duration, and if the heart regains its normal 
vigor and tonus they disappear. 

A murmur at the aortic area rarely occurs independently 
of mitral disease, and it is usually diastolic or double. An 
uncomplicated systolic murmur at the aorta is suggestive of 
congenital heart disease. (Still, Common Disorders of Child- 
hood.) 

Accidental murmurs are rare in infancy, but not uncommon 
in childhood. They occur either as a so-called functional 
murmur over the pulmonary area in acute febrile disturb- 
ances and aneimic states, or at the apex at the end of inspira- 
tion. The name cardio-pulmonary murmur has been given to 
the latter condition; it is most frequently heard in a vigorous, 
overactive heart. A constant murmur found in a child under 
three years old, especially if it be heard most distinctly at the 
base, may be looked upon as congenital. 

Still (Joe. cit.) describes a murmur which he calls "physi- 
ological bruit," occasionally heard in young children, between 
two and six years old. It is usually heard just below the level 



DISEASES OF THE HEAET AND ITS MEMBRANES 237 

of the nipple, about midway between the left margin of the 
sternum and nipple line. In time it is systolic, and it is not 
transmitted. The character is twanging, somewhat musical, 
very like the noise made by twanging a piece of tense string. 

Adherent pericardium is difficult to diagnose. Apert (loc. 
cit.) maintains that the only definite physical sign upon which 
a positive opinion can be based is the invariability of the situa- 
tion of the heart in diverse bodily positions of the patient. 
This is demonstrated by noting the position of the apex beat 
and deep cardiac dulness with the patient standing, recumbent 
and lying on the right side. The chief clinical symptom in 
his belief is progressive asystole rebellious to any form of 
treatment. Personally I am of the opinion that systolic re- 
traction of the chest wall in the cardiac region, if properly 
interpreted, is a diagnostic sign of great value, as is also a 
heaving, diffuse impulse associated with diastolic shock and 
diastolic collapse of the jugular veins. In a heart that is not 
markedly enlarged these signs are even of greater significance. 

Treatment. — The treatment of heart disease resolves itself 
into prophylaxis, care during an acute attack or during an 
exacerbation of an old endocarditis, and the care of the child 
during periods of quiescence. 

The chief prophylactic measure in the present state of our 
knowledge of rheumatic infection is attention to the throat. 
All colds in the head should receive prompt attention; ade- 
noids and diseased or abnormal tonsils should be removed. 
Attacks of laryngitis and bronchitis, especially if recurring 
in nature, should be viewed with suspicion. 

The diet should be generous and nourishing, and largely 
lacto-vegetarian, although meat is not contraindicated. Owing 
to the tendency to anemia, eggs and meat must enter into the 
diet with moderation. Fats are of the greatest importance, 
and in the winter time cod liver oil should be given. 

Cold baths are not well tolerated by rheumatic subjects, 
and a damp, chilly climate is a disadvantage to these cases, 



238 DISEASES OF CHILDREN 

although clear, cold weather is beneficial. The clothing 
should be of wool throughout in cold weather. Exposure to 
others suffering with colds and sore throat is to be strictly 
avoided. 

During an attack of endocarditis, absolute rest in bed must 
be enforced until the pulse and temperature have been normal 
for two or three weeks. There is less danger of the patient 
becoming weak from lack of exercise than there is of straining 
a weakened heart muscle, and relighting the endocarditis. 
General massage may be employed during the period of 
convalescence. 

At the end of this period also, if the heart remains enlarged 
and shows deficient tonicity and the peripheral circulation is 
poor, the Nauheim baths and resisted movements may be 
employed to great advantage. 

Aconite is the best remedy in the early stages, when the 
inflammatory process is at its height and the pulse is rapid 
and the patient nervous and restless. Chilliness, palpitation, 
stitches about the heart, precordial distress and anxiety are 
keynotes for this remedy. 

Bryonia is pre-eminently indicated in pericarditis, but its 
specific affinity for serous membranes also makes it valuable 
in endocarditis. When the patient is weak and indifferent, 
with continued fever, headache, great thirst, general rheu- 
matic aching and soreness in the cardiac region, bryonia is the 
remedy indicated. In endocarditis and pericarditis, with 
violent palpitation and stitching pains about the heart, spigelia 
is indicated. 

In myocarditis arsenicum alb., cactus and digitalis are to 
be considered. When decompensation occurs, we may have to 
depend upon the physiological effect of digitalis to tide the 
patient over the crisis. Convallaria is a remedy which should 
also be considered in this condition, especially when the pulse 
is rapid and irregular, and the patient is conscious of the 
disturbed heart's action. 



DISEASES OF THE HEART AND ITS MEMBRANES 239 

After the acute manifestations have subsided, the iodide of 
arsenic 3x trit. administered for several weeks often improves 
the child's general condition and cardiac action markedly. Fer- 
rum phos. may also be of value if there is a secondary anemia 
with shortness of breath on exertion and kali carb. when there 
is a slight edema of the ankles at the close of the day. 

For general rheumatic disturbances rlius tox. is most fre- 
quently indicated. The recurring rheumatic sore throat sug- 
gests guiacum. An occasional dose of sulphur may be admin- 
istered where chronic arthritis or cutaneous manifestations are 

noted. 

MYOCARDITIS. 

Acute degenerative and inflammatory changes in the heart- 
muscle are of frequent occurrence in the acute infections of 
childhood. The toxins of diphtheria, scarlet fever and typhoid 
fever are especially concerned in the production of myocardial 
degeneration (Romberg). True inflammatory changes — myo- 
carditis — are most frequently associated with endo- and peri- 
carditis, and are due to the invasion of the heart-wall with 
pyogenic organisms, chiefly the streptococcus pyogenes, staphy- 
lococci and pneumococcus (Ziegler). Myocardial changes have 
also been observed in whooping-cough by Koplik and Osier. 
Pyrexia is a contributing cause, but does not seem able to pro- 
duce myocarditis by itself. 

The varieties of degeneration encountered are granular, 
hyaline and vacuolar. All of them may have more or less fatty 
changes associated. The process may be purely degenerative 
throughout, but, as a rule, exudation and cell proliferation in 
the connective tissue stroma is associated therewith. In infec- 
tious and pyemic cases areas of round cell infiltration play 
a prominent role, which may break down, resulting in small 
intramural abscesses. 

At autopsy the heart is found of a pale, yellowish-brown 
turbid color and the muscle is easily torn. It is the soft-heart 
of the older writers. The process is mostly diffuse, although 



240 DISEASES OF CHILDREN 

in true myocarditis the changes may be more pronounced in 
different areas. 

The symptoms are essentially those of a weak heart. When 
myocarditis develops during the course of typhoid fever or 
pneumonia the pulse becomes weak and often irregular, the 
pulse respiratory ratio is too high and the first sound of the 
heart too weak to be accounted for by the fever alone. In the 
absence of demonstrable peri- and endocarditis we suspect that 
we are dealing with a degenerated myocardium. In the course 
of diphtheria the child may suddenly be seized with epigastric 
pain ; vomiting, syncope; rapid, irregular pulse. Such symp- 
toms are of the gravest prognostic significance. 

The softening of the heart muscle invites dilatation ; there is, 
therefore, usually some dilatation, especially of the right ven- 
tricle. A faint apical systolic murmur may be present. The 
heart is usually rapid and embryocardiac in rhythm. Brady- 
cardia may develop, especially after diphtheria. On the other 
hand, there may be no symptoms, or only a short time before 
death will there be sufficient indications to make us suspect 
myocarditis. 

The diagnosis of myocarditis cannot always be made during 
life, but there are certain symptoms that strongly point to its 
existence. The subject is well summarized by Koplik {Med. 
News, March, 1900) as follows: Attacks of faintness, pallor, 
vomiting; disturbed and irregular heart's action; persistent 
distortion of the respiration and pulse ratio as in adherent peri- 
cardium. When these attacks show a tendency to recur they 
are certainly significant. Physical examination reveals a weak 
apex-beat, weakness of the first sound or loss of its muscular 
quality, greater intensity of the second sound at the apex and 
accentuation of the pulmonary second sound. In pertussis there 
is in addition slight systolic blow at the apex, edema of the 
face and extremities, pallor, cyanosis and drowsiness. 

The prognosis is grave. Under long-continued rest the heart 
may regenerate sufficiently to resume its function as before, 



DISEASES OF THE HEART AND ITS MEMBRANES 241 

providing the changes have not been too extensive. The symp- 
toms described as indicative of myocarditis are in reality due to 
dilatation (Osier). The abrupt death in the course of an acute 
infectious disease results from cardiac paralysis. 

The treatment calls for the most complete rest. As long 
as symptoms show the slightest tendency to recur the child 
should not be permitted to sit up or make the slightest physical 
exertion. The remedy most homeopathic to the degenerative 
changes is phosphorus, and it is undoubtedly of value. The 
iodide of arsenic, cactus, digitalis and kali carb. should also 
be studied in connection with the case (see treatment of "Endo- 
carditis"). Mild alcoholic stimulation is usually of value. As 
an emergency remedy, Holt speaks highly of morphia. 



17 



CHAPTER XI. 

DISEASES OF THE KIDNEYS AND URINARY TRACT. 

Albuminuria occurring during the course of the acute infec- 
tious diseases is the most frequent renal disturbance encount- 
ered in childhood. It is usually due to an acute parenchyma- 
tous degeneration of the kidney and not to an actual nephritis 
and is, therefore, a transient condition. True nephritis is 
rarely seen excepting as a complication of scarlet fever. This 
form of nephritis is described as "postscarlatinal nephritis." 

Malformations of the kidney such as congenital hydronephro- 
sis, congenital cystic kidney and the horse-shoe kidney which 
represents a fusion of both kidneys, are occasionally encount- 
ered in autopsies upon infants. Hydronephrosis may be uni- 
lateral or bilateral, presenting a fluctuating tumor in the flank. 
The cystic kidney may be unilateral and if the cysts are of 
large size a firm, smooth renal tumor may be palpated. Cystic 
kidney is often bilateral, the kidneys not being enlarged but 
presenting a surface studded with small cysts of varying size. 
There may be sufficient normal renal tissue present in these 
cases to be compatible with a fair degree of health and a renal 
lesion may, therefore, remain unsuspected. 

Tumors of the kidney are usually malignant, being either 
sarcomata of the embryonal adenosarcoma type or hypernephro- 
mata. Hypernephroma originates in the supra-renal gland or 
from adrenal cells abnormally distributed in the renal tissue 
and is characterized by its rapid growth and tendency to meta- 
stasis. Sarcoma likewise is prone to induce metastasis in the 
bones and distant organs and for this reason renal tumors in 
childhood usually terminate fatally within a year even if the 
tumor is extirpated. 

The symptoms are a rapidly growing, hard, rounded tumor 
of irregular shape first appearing in the loin and encroaching 



DISEASES OF THE KIDNEYS AND URINARY TRACT 243 

upon the abdominal cavity. It is usually painless although 
it may become sensitive from localized peritonitis. Hematuria 
is frequently detected. With the increasing size of the tumor 
pressure symptoms appear and as metastases develop cachexia, 
cough and bony enlargements make their appearance. 

ALBUMINURIA. 

Albuminuria occurring during the course of one of the infec- 
tious diseases is ordinarily due to acute 'parenchymatous degen- 
eration of the kidney and is, consequently, a transient disturb- 
ance. The pathological changes are confined to the tubules of 
the kidney and result from the presence of soluble toxins in the 
blood. Certain drugs as well as endogenous chemical toxins 
originating in the intestinal tract may cause the lesions of a 
"tubular nephritis" for which reason albuminuria is a common 
symptom of the acute intestinal disturbances of infancy as well 
as of the acute infectious diseases. 

The symptoms of acute degeneration of the kidneys are a 
high colored, clear, concentrated, acid urine containing a trace 
of albumin and a few hyaline casts, renal cells and blood cor- 
puscles. There is no edema or tendency toward the develop- 
ment or uremia. The only physiological disturbance noted is 
a delayed sodium chlorid and potassium iodide excretion. The 
albuminuria disappears with recovery from the primary disease 
of which it was but a clinical manifestation. 

POSTURAL ALBUMINURIA; LORDOTIC ALBUMINURIA. 

When albuminuria occurs in a young individual the point to 
be decided is whether we are dealing with a case of nephritis 
or whether the albuminuria is purely a functional and conse- 
quently a temporary disturbance. There is a form of albumin- 
uria which is not uncommonly encountered at the time of adol- 
escense which, if carefully studied, proves to be of functional 
origin and unless the true nature of the condition is recognized 
a serious error in prognosis may be made and inappropriate 
treatment instituted. 



244 DISEASES OF CHILDREN 

Richard Bright in 1827 established the fact that the presence 
of albumin in the urine is an indication of inflammatory 
changes in the kidney and that patients who were afflicted with 
an albuminuria showed the signs of a nephritis at autopsy 
or developed the characteristic clinical manifestations of renal 
disease. For many years after this important discovery was 
made it was believed that every case of albuminuria was a case 
of renal disease, or Bright's disease. Even now this attitude 
is maintained by many clinicians without searching for fur- 
ther evidence of renal pathology outside of the presence of 
albumin in the urine. At the present time, however, the careful 
clinician realizes that albuminuria does not invariably spell 
Bright's disease. Leube repeatedly discovered albumin in the 
urine of soldiers after physical exertion; the albumin disap- 
peared after rest and was never present in the urine voided in 
the morning on rising. Pavy made the discovery that among 
children and young adults cases of albuminuria could be found 
in which the albumin was only present at intervals, or cycles, 
and he designated this condition as Cyclical albuminuria." 
Heubner later shows that the albumin appeared when the erect 
position was assumed and that it was the change from the 
the reclining to the erect position, particularly in the 
morning hours which was responsible for the abuminuria. 
The urine voided when first arising in the morning was free 
from albumin in his cases while that voided several hours after 
being up and about gave a strong albumin reaction. Realizing 
the importance of posture as an etiological factor he called the 
condition "orthostatic albuminuria." 

The etiological relationship of posture to this form of album- 
inuria has been fully established by the observations of numer- 
ous clinicians. Jehle, however, insists that posture is not the 
important factor but that a lordosis, involving especially the 
upper lumbar vertebra, is the actual cause of the condition and 
he has coined the term "lordotic albuminuria" as a substitute 
for postural and orthostatic albuminuria. While the majority 



DISEASES OF THE KIDNEYS AND URINARY TRACT 245 

of patients with an orthostatic albuminuria present a lordosis 
as well as other evidences of physical inferiority, such as the 
Stiller type of physique, nevertheless, we encounter many chil- 
dren and young adults with these physical defects who do not 
have an albuminuria. 

The evidence of organic renal disease is lacking in these cases. 
There are no cardiovascular changes, in fact the blood pressure 
is abnormally low, especially the diastolic. There is no edema 
of the extremities, ocular disturbances nor is uremia to be 
feared. There are no casts in the urine and the albumin is 
part nucleoalbumin. The prognosis is good. As the child's 
physical condition improves the albuminuria improves, in fact 
we are justified in promising the parents that the child will 
"grow out of the condition" in the literal sense of this phrase. 

The treatment of orthostatic albuminuria must therefore be 
a building up process and a diet rich in milk, eggs, fats, an 
abundance of green vegetables and meat in moderate amounts is 
indicated. Fresh air in abundance, out-door exercise and cor- 
rective gymnastics if lordosis and enteroptosis be prominent 
symptoms are to be followed out. Remedies are not required 
for the albuminuria ; casts are seldom found in the urine. Such 
constitutional remedies as calcarea phosphorica, phosphorus, 
and arsenicum are useful, and iron if the child is anemic. 

EDEMA WITHOUT KIDNEY LESION. 

In protracted cases of enteric disturbances it is not uncom- 
mon to find general edema without any clinical evidence of 
nephritis. There is puffiness of the eyelids and a cushion-like 
swelling on the dorsum of the hands and feet. General ana- 
sarca may develop. There is usually a history of an acute gas- 
trointestinal disturbance ' associated with prolonged feeding of 
barley-water, broths and weak milk mixtures. It is, therefore, 
most likely partly toxic and partly dietetic in origin. The 
edema promptly disappears as soon as the infant's general con- 
dition is improved by rational feeding. 



246 DISEASES OF CHILDREN 

HEMATURIA; HEMOGLOBINURIA. 

Hematuria, or blood in the urine, has the same significance 
in infancy as in later life, although it is much less frequently 
due to organic and mechanical causes (papilloma, calculus) 
than to acute nephritis, tuberculous cystitis and general dis- 
turbances, such as hemorrhagic disease of the new-born, pur- 
pura, scurvy. 

Hemoglobinuria, or hemoglobin in the urine, results from the 
action of some toxic agent or ferment upon the blood, through 
which the hemoglobin is dissolved out of the corpuscles and 
excreted with the urine. 

It has been observed in various infections (malaria, scarlet 
fever), in helminthiasis, after exposure to cold as a result of 
certain drugs (potassium chlorate, phosphorus, arsenic). The 
most striking form is recurring hemoglobinuria. This usually 
affects children whose health is below the normal standard and 
in many cases there is evidence of hereditary syphilis. 

ACUTE NEPHRITIS. 

Two distinct types of acute nephritis are encountered in 
childhood, namely acute parenchymatous, or tubular nephritis, 
and acute diffuse, or glomerulonephritis. Both are due to bac- 
terial toxins which reach the kidney through the circulatory 
blood and set up an inflammatory reaction in its parenchyma. 
Tubular nephritis may be induced by bacterial and other toxins 
and by certain drugs and is the variety usually encountered 
complicating the various acute infectious diseases. The most 
severe type of tubular nephritis is encountered in diphtheria. 
The most important clinical type of acute nephritis, however, 
encountered in childhood is the glomerulo-nephritis which fol- 
lows scarlet fever. This is also known as post-scarlatinal neph- 
ritis and it differs both pathologically and clinically from the 
other forms of nephritis seen in childhood. Some cases of 
glomerulo-nephritis are attributed to tonsillitis and septic 



DISEASES OF THE KIDNEYS AND URINARY TRACT 247 

(streptococcic) sore throat. In such cases there has probably 
been an unrecognized scarlet fever since the rash may have 
been overlooked although the throat symptoms were noted. In 
recent cases of nephritis it is not uncommon to find signs of 
desquamation still in evidence although the child was not known 
to have had scarlet fever. 

Pathology. — The kidney may or may not show gross 
changes. Usually it is enlarged, congested and the capsule is 
tense but not adherent. The cut surface is grayish or of a 
mottled red appearance and the parenchyma is soft and mushy. 
Punctate hemorrhages are usually dispersed throughout the par- 
enchyma and blood and serum ooze from the cut surface. The 
glomeruli are seen as red or grayish points in the glomerular 
type. The pyramids are of a dark red color and stand out in 
sharp contrast to the cortex. 

Necrotic changes in the epithelial cells of the tubules with 
some inflammatory reaction of the interstitial tissue are the 
chief findings in tubular nephritis. In severe diphtheritic cases 
the desquamative changes are very pronounced. In glomerulo- 
nephritis all of the renal elements are involved so that the term 
acute diffuse nephritis may be used synonymously with glo- 
merulo-nephritis. However, since the glomeruli are especially 
attacked by the scarlatinal virus and since the renal function is 
so seriously crippled by this lesion, the term glomeruloneph- 
ritis is both a good clinical and pathological one. 

Symptoms. — The presence of albumin in the urine and a 
few hyaline and granular casts in a patient with an acute infec- 
tion is significant of an acute parenchymatous degeneration of 
the kidneys. With the development of an actual nephritis the 
urine becomes scanty and high colored; it contains a large 
amount of albumin together with red and white blood cor- 
puscles, blood and epithelial casts and renal epithelium. The 
clinical manifestations of tubular nephritis are not character- 
istic excepting for the urinary findings mentioned. In glo- 
merulo-nephritis, however, dropsy and uremic manifestations 
develop in conjunction with the albuminuria and cylindruria. 



248 DISEASES OF CHILDREN 

A primary nephritis is ushered in with high fever, pain in 
the region of the kidneys, headache and vomiting, scanty urine 
and later anasarca. 

When secondary to an infectious fever the symptoms develop 
less abruptly. They make their appearance at the height of 
the fever or during convalescence as occurs in scarlatina. Fre- 
quently a renal affection is not suspected until dropsy and 
scanty urine are noted. Post-scarlatinal nephritis appears, as 
a rule, in the third or fourth week of the disease. 

Dropsy is naturally most noticeable in those portions of the 
body possessed of loose areolar tissue, and for this reason the 
face, particularly the eyelids, the wrists and ankles, legs and 
scrotum, become most markedly affected. The pleural and peri- 
toneal sacs may also become involved. 

Dilatation of the heart, indicated by an increase in the area 
of cardiac dulness and weak pulse, is a frequent complication 
arising during the course of nephritis. The urine is diminished 
in quantity, the specific gravity high, although the amount of 
solids excreted is far below the normal. Its color is dark-red 
or smoky, the latter indicating the admixture of blood and it 
contains a large amount of serum albumin; leucocytes; renal 
epithelium and casts. Blood and narrow hyaline casts occur 
early ; later epithelial, granular and broader hyaline casts make 
their appearance. 

Dropsy is frequently the first symptom noticed. In other 
cases uremic manifestations, namely headache, vomiting, sup- 
pression of urine — are the first clinical evidence of the disease. 
In favorable cases the anasarca promptly subsides under treat- 
ment and the albumin and casts disappear from the urine in the 
course of a few weeks. The severe type of cases with suppres- 
sion of urine and uremic symptoms frequently prove fatal. 
Instead of the coma and convulsions of uremia the air hunger 
(hypernea) of acidosis may develop and the child die with 
symptoms of acidosis in place of those of uremia. 

The outlook as to the ultimate condition of the kidneys in 



DISEASES OF THE KIDNEYS AND URINARY TRACT 249 

cases which have recovered from the acute symptoms is gen- 
erally good. A trace of albumin may persist for months in the 
child's urine but few cases of chronic nephritis in adults can be 
traced back to an attack of acute nephritis in childhood. The 
possibility, however, of a latent nephritis persisting throughout 
adolescence should always be borne in mind. 

Treatment. — Prophylactic measures should be carried out 
during the course of all acute infectious diseases, particularly 
during scarlet fever. The urinary output should be kept high 
by giving the child water freely and a low protein diet should 
be enforced. The chief foods allowed should therefore be fruit 
juices, milk and cereals. The child should be kept in bed for 
some time during convalescence especially if the renal function 
be impaired and the body surface carefully guarded against 
being chilled. Daily tepid sponge baths should be given to 
maintain a good skin function. Daily bowel movements should 
also be secured through the use of enemata. 

When anasarca develops gentle sweating may be induced by 
means of warm packs but this procedure must not be carried to 
the extreme. The amount of fluids administered should be 
somewhat reduced but not entirely cut out. A mild saline 
laxative may be given daily in place of the enema. 

For uremic symptoms and suppression of urine a warm bath 
may be given followed by a gentle sweat and a high, warm rectal 
enema administered. Salt should not be added to the enema as 
it interferes with the renal elimination. A teaspoonful of 
bicarbonate of soda to a quart of water, however, is advantageous 
as there is usually a certain degree of acidosis associated with 
the uremic symptoms. 

Arsenicum is indicated by the anemia and anasarca, especially 
prominent about the eyelids in the morning. There is scanty 
urine, the characteristic thirst and restlessness, and cardiac 
involvement. 

Apis is frequently called for, and is most useful for conditions 
which arise suddenly, especially during the course of an acute 



250 DISEASES OF CHILDREN 

disease ; the urine becomes scanty or suppressed, general dropsy 
develops, and pulmonary edema may set in. Other characteris- 
tic symptoms of apis are cerebral involvement, with coma, shrill, 
piercing cry, and convulsions. 

Cantharis is strictly homeopathic to acute nephritis and has 
been found a useful remedy by both schools of medicine. It 
is helpful for the very acute symptoms which may arise, such 
as high fever, tearing pains in the kidneys, vesical tenesmus, 
retention of urine and uremic coma; also in the later stages, 
to remove the albumin from the urine. 

Hepar. — Urine decreased in quantity and containing blood, 
albumin and hyaline casts. Kafka's experience was "No rem- 
edy will act quicker or surer than hepar sulph. 3. in the case of 
dropsy and albuminuria occurring during scarlet fever" 
(Homeopatische Therapie). His reason for using this remedy 
was on the grounds of the relationship of hepar to croupous 
inflammation. 

Lachesis and terebinthina, especially the latter in post- 
scarlatinal nephritis, are indicated in hemorrhagic nephritis. 
In lachesis the urine is very dark in color, and the characteristic 
subjective symptoms of the drug may be present. The urine 
indicating terebinth, is highly albuminous and scanty, the 
color being "smoky," due to the abundant admixture of blood. 
Helleb. is also prominent in hematuria. 

Uremic convulsions call for cicuta, bell., hyos. or stramo- 
nium; the arsenite of copper seems particularly applicable to 
all forms of uremic conditions and is the remedy most to be 
relied upon. 

All complications, such as serous effusions, edema of the 
lung, etc., must be dealt with purely symptomatically. The 
resulting anemia most frequently calls for arsen., hali carb., 
ferrum metallicum. 



DISEASES OF THE KIDNEYS AND URINARY TRACT 251 

CHRONIC NEPHRITIS; BRIGHT'S DISEASE. 

Chronic nephritis may develop from an acute nephritis, 
especially after the post-scarlatinal form. It may occur as a 
complication of a chronic infectious disease such as tuberculosis, 
syphilis and long-standing suppurative processes. Often it is 
idiopathic, with perhaps a hereditary factor in its etiology. 
There are two types of chronic nephritis, the parenchymatous 
and the interstitial. 

CHRONIC PARENCHYMATOUS NEPHRITIS. 

In this form the kidney is much enlarged, presenting a 
yellowish-white appearance (large white kidney). On section, 
the cortex is found thickened and swollen and light in color, 
while the pyramids retain their dark-red hue. 

The epithelium of the tubules is swollen and degenerated ; the 
tubules contain degenerated cells and coagulated fibrin. Hyper- 
plasia of the interstitial connective tissue and nuclear prolifera- 
tion in the glomeruli and their capillaries together with 
amyloid degeneration of the smaller vessels, are the histological 
lesions. Delafield sums up the pathology of the whole condition 
in the name he gives it, namely, chronic productive nephritis 
with exudation. Amyloid changes in the blood vessels of the 
glomeruli are common in the nephritis of childhood. 

Symptoms. — As a rule, the first symptom leading us to 
suspect a nephritic condition, aside from the discovery of al- 
bumin and casts in the urine, is anasarca. This is first noticed 
as a puffiness of the face, especially of the eyelids. Often there 
is a rapid increase in the dropsical manifestations and the legs 
share in the edematous process while the abdomen becomes 
more and more distended until an ascites can be detected. 

The renal function is markedly disturbed. There is a marked 
reduction in the urinary output and the specific gravity is 
relatively low. There is consequently defective elimination of 
nitrogenous waste with an increase of non-protein nitrogen in 



252 DISEASES OF CHILDREN' 

the blood. A relative acidosis also develops from faulty excre- 
tion of inorganic salts. The urine shows a high percentage of 
albumin and microscopic examination reveals degenerated 
epithelium; hyaline, granular, epithelial and, at times, 
fatty casts. 

The course of the disease may cover a number of years with 
periods of remissions and apparent cure. Some cases undoubt- 
edly do make a complete recovery for this is more likely to occur 
in a child than in an adult. In the majority of cases, however, 
the outlook is unfavorable, death ultimately resulting either 
from uremia or circulatory failure. The average duration is 
about two years. 

Uremia is usually ushered in by headache and vomiting, 
followed by convulsions and coma. In children convulsions 
are more common than in adults; the same may be said of 
acidosis. Uremia is not so liable to develop when amyloid 
changes are marked in the kidneys, which can be suspected from 
the freer urinary secretion and the coexisting enlarged liver 
and diarrhea. 

CHRONIC INTERSTITIAL NEPHRITIS. 

This is a rare form of nephritis in children, and its etiology 
is unknown. Syphilis, tuberculosis, arteriosclerosis and heredity 
have been considered as causes, and in some instances it has 
apparently followed an acute infectious or eruptive fever. 
Allan Baines (Archives of Pediatrics, 1901) reports a pro- 
nounced case of arterio-sclerosis with interstitial nephritis 
occurring in a boy ten years old. The etiology in this case was 
obscure excepting that he had rheumatism and chorea. In the 
cases which I have personally seen no etiological factor could 
be determined. Guthrie has lately reported seven cases in the 
"Lancet." He considers it, not a product of parenchymatous 
atrophy, but an interstitial inflammatory process with round cell 
infiltration of the stroma of the kidney, beginning in the cortex 
and spreading in the form of bands to the center of the organ. 



DISEASES OF THE KIDNEYS AND URINARY TRACT 253 

The urine is pale and abundant, low in specific gravity, and 
contains a small percentage of albumin, which may only be 
present at certain times. Such an albuminuria occurring 
several years after an infectious disease, the albumin being 
especially found in the morning urine, together with hyaline 
and granular casts, is a strong evidence of interstitial nephritis. 

Dropsy seldom develops, but persistent gastro-intestinal 
symptoms and certain nervous disturbances, such as periodic 
headaches, vertigo, or convulsions, together with high arterial 
tension and hypertrophy of the heart, are indicative of con- 
tracted kidney, even in the absence of albumin. The prognosis 
depends much upon the compensation and integrity of the cir- 
culatory system, and the course is more protracted than in par- 
enchymatous nephritis. Uremia or cerebral or other hemor- 
rhage terminate the disease. 

Treatment. — The diet should be restricted in nitrogenous 
food but the minimum protein requirement of the body must be 
met by a certain amount of protein food. This is about 1.5 gms. 
for every kilogram of body weight. When uremic symptoms 
develop all protein must be excluded from the diet. In the 
average case of nephritis milk is the ideal food ; it should hold 
the most prominent place in the dietary, and it can be modified 
in many ways to vary the monotony of its administration. 
Fresh vegetables, fruit and cereals, are all allowable. There is 
danger of giving too much water and other fluids in these cases, 
as von ISToorden has pointed out. The damage done to the heart 
and arteries may be greater than the good accomplished by this 
excessive "flushing of the kidneys." 

The function of the skin should be promoted and the cutane- 
ous circulation stimulated by tepid sponge-baths, followed by 
vigorous rubbing. The undergarments must be of wool, to 
protect against any sudden chilling. 

Water should be drank regularly between meals, in modera- 
tion; such springs as Poland, Bedford and Waukesha, or a 
distilled water, are especially beneficial in keeping up a sufficient 
excretion of urinary solids. 



254 DISEASES OF CHILDREN" 

The measures recommended for dropsy and uremia under 
acute nephritis are equally applicable here. Diuretics are 
contraindicated in the edema of nephritis. The remedies most 
useful for the nephritis itself are apis, arsenicum, aurum mur., 
canth., mere, cor., phos. and plumbum. These remedies are 
strictly homeopathic to the pathological process in the kidney, 
and have proven themselves of great clinical value. Aurum and 
plumbum are particularly related to the interstitial form 
of nephritis. 

DIABETES INSIPIDUS. 

Diabetes insipidus is a chronic form of polyuria occasionally 
encountered in childhood, but like diabetes mellitus it is a 
comparatively rare disease. It differs from diabetes mellitus in 
the absence of sugar in the urine and from the polyuria of 
interstitial nephritis in the absence of high blood pressure and 
absence of albumin or casts in the urine. 

The etiology and pathology are obscure; heredity, traum- 
atism to the nervous system and organic brain disease, however, 
seem to bear distinct relationship to some cases, and it has 
occasionally developed after the infectious fevers. Disease of 
the pituitary gland may be responsible for some cases. 

The pathognomonic symptoms are polyuria and great thirst; 
the urine is pale and limpid, of low specific gravity, and contains 
neither sugar nor albumin. Associated symptoms are loss of 
weight, impaired digestion, constipation and functional nervous 
disturbances. The onset is usually gradual and the course a 
prolonged and tedious one, either ending in recovery or in death 
from exhaustion or some intercurrent affection. The prognosis 
is not altogether unfavorable, especially in the case of children, 
but a definite cure cannot be promised. 

Differential diagnosis rests between diabetes mellitus and 
interstitial nephritis. From the former it is readily distin- 
guished by the low specific gravity of the urine, the absence of 
sugar, as well as lack of marked and rapid emaciation. Inter- 
stitial nephritis is associated with arterio-sclerosis, high blood 



DISEASES OF THE KIDNEYS AND URINARY TRACT 255 

pressure, hypertrophy of the heart and -uremic manifestations 
and repeated careful examinations of the urine seldom fail to 
find albumin and hyaline casts. The ingestion of salt increases 
the urinary output in diabetes insipidus while in nephritis there 
is delayed salt excretion. Hysterical polyuria is emotional in 
origin and only a temporary disturbance. 

The remedy which has yielded the most satisfactory results 
in my hands in cases of persistent polyuria, when the patient 
urinates freely every hour or two during the day, and from four 
to six times during the night, the urine being pale and limpid, 
is natrium muriaticum, 6th dilution. Thirst may be a prom- 
inent symptom, together with constipation, etc. 

Ignatia is occasionally useful in highly nervous tempera- 
ments. Goodno has obtained positive results from strophanthus 
lx. Hughes recommends scilla 2x; Schuessler, ferrum phos. 
lx. The administration of pituitary gland promises to be 
helpful in some cases. 

DIABETES MELLITUS. 

Glycosuria is frequently encountered in young children 
during the course of an acute gastrointestinal disturbance and 
is one of the chief symptoms of Finkelstein's "Alimentary 
Intoxication. " Such a glycosuria is, however, transient in 
character and does not indicate a permanent carbohydrate 
intolerance. 

True diabetes is very rare during childhood, and its pathology, 
etiology and symptomatology are identical with the diabetes of 
adults. The course, however, is more rapid, and it is almost 
invariably fatal. The disease may terminate in a few months 
with diabetic coma; or if it is a mild case, amenable to treat- 
ment, it may run for years. The outlook for a case of diabetes 
in a child must necessarily always be unfavorable because the 
restricted diet which is necessary to control the diabetes proves 
inadequate for the needs of the growing organism and while 
the glycosuria may be held in check, serious malnutrition is 
the inevitable result of the treatment. 



256 DISEASES OF CHILDREN 

Diabetes is fortunately rare in children. The disease is 
being recognized more frequently and Joslin has found 4.7 per 
cent of his cases occurring during the first decade against 1 per 
cent of other writers on the subject. 

The etiology is still obscure. Heredity no doubt plays an 
important factor. I have on several occasions encountered 
diabetes in the children of diabetic parents and have seen cases 
of two and three successive children in the same family succumb 
to the disease. Syphilis does not appear to be an etiological 
factor. Obesity is a predisposing cause in children as well as in 
adults; also overeating. Infections, no doubt, play an impor- 
tant role. Disease of the pancreas is the basal etiological factor. 
Cushing has called attention to the relationship of the hypoph- 
ysis to glycosuria. 

Symptoms. — Allen defines diabetes as deficiency of pancre- 
atic amboceptor. According to his belief glucose normally ex- 
ists in the blood in the form of a colloid, due to its combination 
with a substance which is probably the internal secretion of the 
pancreas and which he calls "pancreatic amboceptor." When 
this substance is lacking the glucose acts as a crystalloid and thus 
produces diuresis and is also lost to the body tissues. Another 
important fact relating to diabetes is that the normal tolerance 
for carbohydrates is lost and that the more sugar is taken by the 
individual the more is lost and the lower his carbohydrate 
tolerance becomes. — (Allen's paradoxical law.) 

The pathognomonic symptoms of diabetes mellitus are poly- 
uria, voracious appetite and great thirst, with usually constipa- 
tion and indigestion, marked and rapid emaciation, dryness of 
the skin and nervous disturbances, such as formication and neu- 
ralgia. The urine contains glucose, and its specific gravity is 
high. Heightened susceptibility to infections, especially to 
tuberculosis is characteristic of diabetes. The greatest danger, 
however, lies in the development of diabetic coma, which usu- 
ally causes the death of the patient. The coma is probably the 
culmination of a gradual increasing acidosis which has devel- 



DISEASES OF THE KIDNEYS AND URINARY TEACT 257 

oped beyond the point of control by the various defensive 
mechanisms of the body. 

Treatment. — The first step in the treatment is dietetic. 
Goodno recommends the employment of a diet absolutely free 
from carbohydrates until the glucose disappears from the urine, 
then gradually increasing the dietary and noting the effect of 
each new article upon the urine. Yon Noorden's method of 
gauging the diet in diabetes is the most accurate and scientific 
of all recent contributions to the literature of this subject. It 
is clearly set forth by Lawrence in the N. Amer. Jour, of Horn,, 
Jan., 1904. When the acetone and diacetic acid are persistently 
present in the urine it is necessary to allow the patient a certain 
amount of carbohydrate. An occasional fast day, as carried out 
by Allen, usually clears the acetone from the urine and raises 
the sugar tolerance. 

Meat, fish, eggs, all green vegetables of the 5 per cent carbo- 
hydrate class, fats and oils, gluten bread and butter-milk should 
constitute the diet list as far as possible. Water should be 
drunk freely. 

Cases with acidosis which cannot be made sugar free by the 
ordinary diets may need an occasional continued fast until the 
urine contains neither sugar nor diacetic acid. In order to 
avoid the occurrence of coma in such cases the fast should not 
be abruptly started but fat should be omitted from the diet for 
a day or two; then continue a gram of carbohydrate per kilo- 
gram of body weight for twenty-four hours in the form of 
orange- juice or oatmeal gruel. Give water freely both by 
mouth and by rectum if necessary. Keep the patient in bed 
and warm during the fast. Move the bowels by enemata but 
avoid cathartics (Joslin). Bicarbonate of soda is helpful in 
acidosis but the excessive use of this salt has done more harm 
than good. 

The following remedies have proven useful in diabetes both 
in respect to the carbohydrate intolerance and for the compli- 
cations likely to occur. 
18 



258 DISEASES OF CHILDREN 

Arsen. — Great emaciation and exhaustion; anemia; intense 
thirst; associated nephritis; complications, such as boils, gan- 
grene, cutaneous eruptions. 

Aurum mur. — Syphilitic dyscrasia; profound neurasthenia 
and mental depression. 

Lactic acid. — Gastric disturbances predominate (uranium 
nitr. ) ; dryness of tongue ; empty feeling in epigastrium ; 
constipation; stools hard and black; sluggish circulation in 
extremities. Administered in the lower dilutions. 

Lye. — This remedy is often indicated by its gastric symptoms 
together with the presence of uric acid in the urine. 

Nux vom. — When the digestive tract is the main seat of 
disturbance; also neuropathic cases with many characteristic 
nervous phenomena, such as formication in the limbs; irrita- 
bility ; numbness and paretic condition of the lower extremities ; 
gouty inheritance. 

Nux-, phosphoric acid and arsenic are perhaps the most 
frequently helpful remedies. 

Phos. ac. — Cases of nervous origin. Profuse urination, with 
pain in back and region of kidneys, accompanied by great 
prostration, emaciation and sleeplessness. Rapid growing 
youths. 

Uranium nitr.— Glycosuria. According to Prout, this 
remedy is especially useful when the disease originates in dis- 
turbances of the digestive tract, in contradistinction to phos- 
phoric acid, which is indicated when it originates in the 
nervous system. 

Rhus aromatica is a favorite remedy with the Eclectic school, 
who credit it with power to control the elimination of sugar 
through the urine. It is particularly indicated when there is 
incontinence of urine, being administered in doses of several 
drops of the tincture, three to four times daily. 



DISEASES OF THE KIDNEYS AND URINARY TRACT 259 

PYELITIS. 

Pyelitis, or inflammation of the pelvis of the kidney, is a 
comparatively common clinical condition encountered in in- 
fancy. It differs from the type of pyelitis encountered in adults 
in the fact that it is clinically a primary affection, while the 
pyelitis of the adult is usually a pyelonephritis secondary to 
stone in the kidney or is a manifestation of tuberculosis of the 
kidney or surgical kidney. 

Infantile pyelitis is characterized by an acute onset associated 
with gastrointestinal symptoms, a febrile period of limited 
duration, the presence of pus and bacteria in the urine, the pus 
usually persisting for some time after the temperature has 
reached normal, and a strong tendency to relapses. 

The etiological factor is in the majority of instances the colon 
bacillus. There is still a difference of opinion as to the mode 
of infection. For some time the belief that the bacillus reached 
the kidney pelvis by way of an ascending infection was the most 
popular one. This theory was based on the fact that pyelitis 
occurred most frequently in female infants and that during 
acute bowel disturbances the colon bacillus found its way 
readily into the urethra and could thence be carried readily into 
the bladder and into the ureters. Another mode of infection 
which was considered to be more probable from the anatomic 
standpoint is by way of the intestinal walls directly into the 
genitourinary tract. While such a mode of infection is very 
likely probable, still it does not seem likely to occur excepting 
in very rare instances. The most probable mode of infection 
in the majority of cases appears to be by way of the circula- 
tion. The grounds for this belief are that pyelitis is not a 
primary condition but develops during the course of an acute 
gastrointestinal infection. The child is sick with high fever, 
vomiting, distended abdomen and foul stools for several days 
before pus is discovered in the urine. After the pelvis of the 
kidney has become infected the urinary symptoms will persist 



260 DISEASES OF CHILDREN 

for some time even though the intestinal condition has been 
cleared up. Relapses also may occur either from a persisting 
renal focus or from re-infection from the intestines. The 
argument advanced against the theory of infection by way of 
the blood stream is that blood cultures in cases of pyelitis 
are negative. This argument, however, cannot hold for it is 
a well-known fact that bacteria may rapidly disappear from the 
blood in certain infectious diseases but may be demonstrated in 
the urine for a long period after the blood has become sterile. 
This is notably the case in typhoid fever in which disease blood 
cultures are only positive in the first week while the urine may 
still be strongly positive for typhoid bacilli in the third week. 
Symptoms. — Pyelitis is rarely recognized from its symptoms 
since there is nothing distinctive about its clinical course. We 
should always suspect pyelitis as the most probable cause of an 
obscure fever in an infant if an infectious diarrhea or pneu- 
monia can be ruled out. This applies particularly to the milder 
type of case in which fever is the chief symptom. The fever 
is continuous, usually lasts about ten days and has a distinct 
tendency to recur. 

The more severe type of case is abrupt in onset with a distinct 
chill or its equivalent, high fever, vomiting, distended abdomen, 
offensive stools. Tenderness over the kidneys may develop and 
the child holds itself rigidly and shows evidence of pain in the 
back. Painful urination may also be observed. The clinical 
picture is at first confusing since the gastrointestinal symptoms 
are the predominating ones. There is often a history of some 
indiscretion in diet or a change of milk, and unquestionably the 
original disturbance is an intestinal one. The fever, however, 
continues in spite of catharsis and starvation diet and an exam- 
ination of the urine at this time explains the reason for the 
persistence of the temperature. 

The urine is diminished in quantity, acid reaction, cloudy, 
and on microscopic examination an abundance of pus and 
mobile bacilli will be found. A trace of albumin and a few 



DISEASES OF THE KIDNEYS AND URINARY TRACT 261 

casts, indicating an associated toxic parenchymatous nephritis, 
may also be present. Under appropriate treatment the urinary 
output increases, it becomes pale and clear in color, the reaction 
becomes alkaline and pus gradually disappears. 

Treatment. — In the milder types of pyelitis a careful 
supervision of the infant's diet, the use of a mild laxative such 
as milk of magnesia and the administration of several ounces of 
water between each feeding are the main indications for treat- 
ment. If the urine is rendered alkaline by the administration 
of bicarbonate of soda, the colon bacillus will find a less favor- 
able environment for its existence and is more readily elim- 
inated. An exclusive diet of butter-milk is useful in some of 
the more stubborn cases. 

In the severe forms of pyelitis the intestinal tract should be 
thoroughly emptied by means of a dose of castor oil and the 
infant kept on barley-water, orange-juice and Mellin's food 
with water until starvation stools make their appearance. 
Butter-milk or albumin-milk may then be given. If the case 
is seen early, while the infection is still active and the urine 
acid in reaction, hexamethylenamine may prove useful. It may 
be given in doses of two grains every three hours. As soon as 
the urine becomes alkaline, however, this remedy should be 
discontinued as it is of no value under these conditions. The 
most important thing in the treatment of pyelitis is to urge the 
infant to drink an abundance of water. The water can be 
sweetened, if necessary, or flavored with fruit juices. Five 
grains of bicarbonate of soda may be added to three or four 
ounces of water and given every 2 to 3 hours. If the child 
cannot be made to take a sufficient amount of water by mouth, 
it may be administered by rectum, 4 to 6 ounces at a time. The 
best solution to use is one pint water, one level teaspoonful of 
salt, and one level teaspoonful of bicarbonate of soda. 

The chief remedy for the acute symptoms of pyelitis is 
cantharis 3x dilution. Aconite is indicated at the time of the 
onset of the condition when chill, fever, and renal congestion 



262 DISEASES OF CHILDBED 

are the chief symptoms. If nervous symptoms predominate 
belladonna will be indicated. After pus makes its appearance 
in the urine and the pathological process in the kidney has 
become established cantharis should be given. Merc, corr. is 
indicated in the chronic type. Autogenous vaccines have proven 
useful in the recurring type to overcome the abnormal suscepti- 
bility of the renal pelvis to- the colon bacillus. 

ENURESIS. 

A normal child acquires control over its bladder and bowels 
during the second year so that a child of two years will make 
its wants known and keeps itself clean. Control over the 
bladder during sleep is, however, a little later in its development, 
the average age at which a child is able to pass the night without 
wetting itself being about two and one-half years. Imbecile 
children never gain control over either the bladder or rectum 
while in the mentally and physically backward it is a late 
acquisition. Aside from the normal physiological development 
of the voluntary control of the function of micturition training 
is also a factor to be considered. 

When an apparently normal child of three years or older still 
urinates involuntarily we speak of this condition as enuresis. 
Bed-wetting may persist up to the time of puberty or even later. 
Various sources of reflex irritation and physical defects have 
been blamed for the enuresis. Phimosis, adherent clitoris, 
adenoids and worms have occupied a prominent position in its 
etiology. Rarely, however, are the confirmed cases of enuresis 
helped to any extent by the removal of the conditions named, 
and they, therefore, cannot occupy a place of much importance 
in the etiology. 

Abnormalities of the urine have also been looked upon as 
causative factors. Acid urine, uric acid crystals and oxalate 
of lime crystals in the urine, pyelitis and cystitis may occasion- 
ally be encountered in enuresis and aggravate the same but the 
urine rarely gives evidence of any of these conditions in the 



DISEASES OF THE KIDNEYS AND URINARY TRACT 263 

great majority of cases. A polyuria undoubtedly exists but 
this is of purely nervous origin. 

Enuresis is primarily a neurosis. The mechanism of urinat- 
ing has remained so fixedly a purely reflex act that the bladder 
contracts and empties itself entirely independently of the will 
or consciousness of the child as soon as an afferent impulse of 
sufficient degree reaches the bladder centre in the lumbar cord. 
A normal child has learned to control the bladder by having 
gradually developed an inhibition over the involuntary discharge 
of urine. It becomes conscious of the sensation of a full bladder 
and the desire to urinate and through the inhibitary power 
of the higher cerebral centres over the involuntary centres in 
the cord is able to hold this desire in check. At the will of the 
individual the inhibition is relaxed and through the added help 
of the abdominal muscles the emptying of the bladder becomes 
a purely voluntary process. 

The child afflicted with enuresis is very often unconscious 
of the process of urinating and may wet itself during the day, 
especially at play or when deeply interested in whatever is 
occupying its mind. The deep sleep natural to children is also 
looked upon as an etiological factor not permitting the desire 
to urinate to enter into its consciousness. Abnormal irritability 
of the spinal centre of the bladder is however, the chief cause of 
the trouble. The child with enuresis is, therefore, usually a 
neurotic individual lacking in stability and self-control; often 
afflicted with other nervous or psychic disturbances such as 
stammering, tics, somnambulism, night terrors, etc. There is 
often a neurotic family history or other children in the same 
family have enuresis. Anemia and malnutrition are often 
present but are not necessary factors. The child may appear to 
be normal mentally but it is usually found lacking in the ability 
to concentrate or apply itself for any length of time to any 
one particular pursuit. Since training is such an important 
element in the treatment, this lack of mental discipline offers 
one of the chief obstacles to success. Another difficulty in 



264 DISEASES OF CHILDREN 

eradicating enuresis when the condition is of long standing is 
the fact that it has become a habit. It is, therefore, of the 
greatest importance to institute systematic treatment before the 
process of micturition has become so fixedly a reflex act that the 
voluntary control over the bladder can only be acquired by the 
most painstaking training. 

The diagnosis of enuresis should not be carelessly made. 
Nocturnal enuresis of irregular occurence in older children 
should suggest the possibility of nocturnal epilepsy. Lack of 
control over the bladder present both day and night may be a 
symptom of a spinal lesion. The polyuria of diabetes is at 
times mistaken for enuresis and the urine of all cases should 
be examined as a matter of routine for sugar or evidences of a 
renal or genito-urinary affection. 

Treatment. — In the majority of cases the child wets the bed 
during the early hours of sleep, that is, usually before midnight 
and the habit may become so firmly established that this occurs 
at practically the same hour every night. For this reason the 
child should not be permitted to have any liquids with its supper 
and it should be regularly taken up and made to urinate before 
it has had time to wet the bed. An important point in this 
connection is to entirely awaken the child so that it will be 
conscious of urinating. Many of these patients are such heavy 
sleepers that they can be taken up, made to urinate, and not be 
conscious of the event. The result is that they have the usual 
accident shortly afterwards just as if they had not been taken up. 

Punishment is of no avail. However, suggestion, and train- 
ing, are of the greatest help in educating the child to gain 
voluntary control over its bladder function. The object of 
training is both to strengthen the sphincter of the bladder and 
to increase the inhibitory voluntary control over the same. Both 
night and morning, when the child has a moderately full bladder, 
it should be taught to urinate at command and interrupt the 
process two or three times before the bladder is emptied. 
The mother should give the command to "start" and "stop" and 
the child soon learns to follow these instructions. 



DISEASES OF THE KIDNEYS AND UEINARY TRACT 265 

Sleeping in a cool, well-ventilated bedroom without too much 
bed clothing ; cold sponge baths in the morning ; the removal of 
all sources of reflex irritation such as phimosis, worms and 
adenoids and constitutional treatment for anemia or a neurotic 
temperament, are important and self-evident adjuvants. As 
to medicinal treatment, there is but one drug which possesses any 
specific value in enuresis and that is belladonna. It acts directly 
upon the nervous mechanism of the bladder and its effect may 
be compared to that of digitalis in auricular fibrillation. By 
blocking out the abnormal stimuli to the detrusor centre it 
lessens the irritability of the bladder and makes the acquisition 
of voluntary control possible. In this manner it helps to break 
up the habit of enuresis and is a most important element in 
the treatment especially in the beginning of a case until the 
results from training and general treatment can make themselves 
felt. The dose usually necessary is from five to ten drops of 
the tincture at bedtime. 

VULVOVAGINITIS ; GONORRHEA. 

Vulvovaginitis is a catharrhal inflammation of the mucous 
membrane of the vulva and adjacent parts and in the cases 
encountered in hospital and dispensary practice is most fre- 
quently gonorrheal in origin. It is, therefore, always important 
to make a microscopic examination of a smear of pus from all 
cases of purulent vulvovaginitis. Koplik (1893) cultivated the 
organism, definitely proving its identity. This has been done 
since repeatedly. 

Nonspecific vulvovaginitis is a simple catharrhal process due 
to lack of cleanliness; local irritation, such as smegma, seat- 
worms or masturbation; or it may be but part of a general 
catarrhal condition in scrofulous children. 

There is a form of purulent vulvovaginitis and urethritis 
affecting both male and female childern which is distinctly 
contagious and is due to a diplococcus which does not show, 
however, the staining and cultured peculiarities of the gono- 
coccus (Koplik). 



266 DISEASES OF CHILDREN 

The spread of vulvovaginitis is surprisingly sure and rapid 
when children are brought into close contact, as in a hospital, 
for example. Every precaution should be taken, therefore, to 
prevent contagion. 

Many children contract the disease from mother or nurse. 
It is often difficult to find the original source of infection. Rarer 
modes of transmission are by rape and attempted sexual 
intercourse. 

The gravest aspect of gonorrhea is its complications. Sal- 
pingitis and peritonitis have been observed (Marx; Sanger). 
This leads to death or sterility. It is a rare complication. 
Infection of the eyes — ophthalmia — is constantly to be dreaded. 

Arthritis in children is not infrequently gonorrheal. Holt 
and Kerley have observed that the majority of arthritides that 
were formerly looked upon as being septic are gonorrheal. 
Kimball (N. Y. Med. Record, Nov. 20, 1903) reports eight 
cases of pyemia with joint involvements in infants in all of 
which the gonococcus was demonstrated. ~No primary local 
lesion was present. The majority died during the height of 
the attack. 

One of my cases, an infant three weeks old, developed ophthal- 
mia three days after birth and a week later successive involve- 
ment of the shoulder, elbow and hip- joints. On one hand the 
second finger became involved in a fusiform swelling (dactyl- 
itis) and the wrist was also swollen. The temperature was 
continuously elevated, ranging from 101° to 102.5° F. Dr. 
Sappington obtained pus from the joints in which he demon- 
strated gonococci, verified by cultures on ascitic fluid and agar. 

Treatment. — In the acute stage the local condition is much 
benefited by irrigation with a warm solution of a non-irritating 
silver preparation. One pint of a 1 too 500 solution of protargol 
or albargin may be used twice daily. The vulva and vagina 
are most satisfactorily irrigated through a small, soft rubber 
catheter, which may be gradually introduced into the vagina 
as the secretion from the external parts is flushed away. The 
vulva is then dried and dusted over with boric acid. 



DISEASES OF THE KIDNEYS AND URINARY TRACT 267 

In the subacute and chronic stage permanganate of potash, 
1-1000, may be used every day or two in a similar manner, 
followed by the dusting powder. Sometimes the dry treat- 
ment will give better results than douches. 

In the early stages cannabis indica is indicated, or cantharis 
when there is dysuria. When the discharge becomes profuse 
and yellow pulsatilla is the most useful remedy. In chronic 
cases, sulphur or sepia. 



CHAPTER XII. 

DISEASES OF THE SKIN. 

The skin of the newborn is exceedingly delicate and vulner- 
able and inflammatory reaction in the same is characterized by 
its intensity. It is very susceptible to infections and mild inf ec* 
tions which in an older child induce only superficial pustle for- 
mation (impetigo) may be the cause of a form of pemphigus. 
The skin manifestations of congenital syphilis and of the exu- 
dative diathesis frequently make their appearance in earliest 
infancy. 

At birth the entire body is covered with a waxy secretion, the 
vernix caseosa, which has served as a protective layer to the 
skin during intra-uterine life. The color is a deep red, owing 
to the vigorous surface circulation, and this condition persists 
for about a month. Usually desquamation of the epidermis, 
visible on close inspection, takes place during the second week. 
Jaundice, occurring on the third or fourth day, is encountered 
in about 80 per cent of all newborn infants. 

The skin of the infant, as well as that of the newborn, is 
exceedingly tender and responsive to all forms of local irritation 
and infections. Functional disturbances also play an important 
role in the etiology of the skin diseases of childhood. Sweat- 
ing is rare in infants, normally not noticed before the fourth 
month, and when persistent it is a strong presumptive sign of 
rickets. The use of irritating soaps, excessive bathing, and, on 
the other hand, uncleanliness, are important etiological factors 
in the skin diseases of childhood, next to which improper feed- 
ing ranks. Dietetic errors no doubt are often directly responsi- 
ble for the heightened irritability of the skin to factors acting 
from without as in the case of exudative diathesis. Slight me- 
chanical and chemical irritation of the skin of such an infant 
is followed by a severe inflammatory reaction (intertrigo and 



DISEASES OF THE SKIN 269 

eczema). In some instances the excessive feeding of carbohy- 
drate renders the child especially liable to pyogenic infections 
of the skin. Exposure to contagion, both to the parasitic skin 
diseases and to the acute exanthematous diseases to which chil- 
dren are so liable after they intermingle at school, is another 
reason for the frequent occurrence of skin affections and 
"rashes" among children. 

Most of the skin diseases encountered in adult life may be 
seen in children. Only those conditions which are distinctive 
of childhood and which present certain characteristics dis- 
tinguishing them from the type of the disease as seen in the 
adult will be discussed. 

MILIARIA; PRICKLY HEAT. 

Miliaria is a common form of rash seen in young infants and 
results from hot weather or too much clothing. It is due to 
excessive perspiration which causes a mild inflammatory reac- 
tion about the mouths of the sweat ducts. The rash consists 
of very superficial, closely aggregated, tiny red papules often 
interspersed with sudamina due to the occlusion of the mouth 
of a sweat gland. It is of sudden onset and under proper man- 
agement fades out in a few days. The site of the rash is usually 
the chest and back, about the neck, and on the face. Itching is 
associated. There is no fever, but a febrile condition may be 
the cause of an attack of miliaria and so the condition is fre- 
quently mistaken for one of the eruptive fevers. Rachitic 
infants are especially liable to develop miliaria. 

The treatment demands first of all the proper dressing of 
the child, removing excessive clothing and woolen undershirts 
where these have been worn and the correction of any under- 
lying condition which is acting as a predisposing cause (rickets ; 
intestinal indigestion) . Sponging the body with a two per cent 
solution of boric acid followed by the generous use of a dusting 
powder gives prompt relief. 



270 DISEASES OF CHILDREN 

ECZEMA. 

Eczema is an inflammatory reaction of the skin resulting 
from some form of local irritation and is indicative of a con- 
stitutional irritability of the skin rendering the individual sus- 
ceptible to this affection. Pathologically it is a catarrhal type 
of inflammation which begins in the corium in discrete punc- 
tate areas whence the process extends to the epidermis with the 
development of erythema, papules and later vesicles upon the 
cutaneous surface. It develops in patches composed of finely 
aggregated papules which increase peripherally and may thus 
affect extensive areas. The lesions present indicate the stage 
of the disease. They are as follows, appearing in the order 
named : 

The stage of erythema in which the skin is red, tense and 
slightly edematous. 

The stage of 'papules, or papular eczema characterized by the 
appearance of small, red, closely aggregated papules forming 
plaques, or patches of eczema. 

The stage of vesiculation, or vesicular eczema in which the 
papules are converted into fine vesicles filled with serous exu- 
date. 

The stage of secondary infection, or pustular eczema. Pustu- 
les are formed and when these burst or are broken by scratching 
the pus and serum which has collected on the skin surface dries 
into a crust. As the inflammation subsides and the oozing sub- 
sides the final stage of desquamation, or eczema squamosum 
develops. The various stages of eczema can usually be observed 
in different parts of the body as a new patch may arise in one 
locality while an older one is approaching the healing stage. 

Infants who develop eczema usually show distinct evidence of 
the exudative diathesis. It may also result from overfeeding in 
breast-fed and is not confined to artificially fed infants. Hered- 
ity may be a factor as well as disturbances in the endocrine 
glandular system. Concerning the latter nothing definite is 



DISEASES OF THE SKIN 



271 



known excepting that some types of eczema are benefited by 
the administration of glandular products. Protein sensitization 
is also noted in some cases and a definite relationship of the 
skin eruption with the feeding of certain proteins (eggs, wheat, 
nuts, etc.), can be demonstrated in these cases. 

Two distinct clinical types of eczema are encountered in 
infants, namely the acute, moist type confined mainly to the 
head and face which occurs in fat, overnourished infants and 
the chronic disseminated type seen in undernourished infants. 

The moist, crust-forming type of eczema (eczema rubrum) 
which is usually encountered in well-nourished infants first 
appears on the face and its onset should be suspected from the 
abnormal redness of the cheeks which is the starting-point of 
the condition. The eruption goes through the various stages 
of an eczematous inflammation in rapid succession, namely 
papules, vesicles, pustules, oozing and crust-formation. In 
typical cases the process spreads to the forehead, eyes and 
neck while the scalp is covered with a scurfy seborrheic dermati- 
tis. Secondary infection of the scalp with the formation of 
boils frequently occurs and the superficial lymphnodes of the 
scalp and neck are enlarged. The eczema may extend to the 
body although in the majority of instances the head alone is 
affected. 

There is marked itching as a result of which the child con- 
stantly scratches and rubs the affected parts thus keeping them 
in a state of irritation and favoring infection and spread of the 
process. Bleeding usually results from the relentless scratch- 
ing of the raw, oozing surface. One of the chief difficulties 
encountered in the treatment of these cases is the relief of the 
itching and the control over the scratching. 

Eczema rubrum usually develops during the first half of the 
infant's life and runs a stubborn course, marked by ameliora- 
tions and exacerbations. It responds more promptly to con- 
stitutional and dietetic treatment than the disseminated type 
and can usually be gotten under control in the course of several 
weeks and eradicated before the child is a year old. 



272 DISEASES OF CHILDBED 

The chronic disseminated form develops later in infancy, 
usually toward the end of the first year and may persist in 
showing some evidence of its activity for a number of years. It 
occurs in infants showing signs of malnutrition and the lesions 
are mainly seen upon the trunk and extremities. They consist 
of numerous disseminated areas of scaly patches. The bends 
of the elbows and of the knee-joints are localities where the 
disease is likely to be most persistent and constantly noted. 
There is less itching than in the moist form but it is very 
stubborn in its course and difficult to eradicate. The skin 
covering the buttocks is often infiltrated and thickened and kept 
in a constant stage of irritation from the urine and stools. 

The treatment of eczema is both local and constitutional. 
In cases of eczema rubrum the amount of food should be cut 
down and the use of skimmed milk or buttermilk often results 
in immediate improvement in the symptoms. In the dry form 
of eczema the exclusion of carbohydrates from the diet is often 
beneficial. Cod liver oil is beneficial in both forms. It is 
always expedient to wean the infant from an exclusive milk 
diet as early as possible and add vegetable broths or strained 
vegetables to the diet. 

Local measures should be mainly sedative in character. 
Bathing should be avoided and the skin should be cleansed with 
olive oil or other bland washes (starch-water; bran-baths; weak 
alcoholic solutions, 30 per cent containing one half of one per 
cent of salicylic acid). Itching may be controlled by means of 
olive oil and lime-water, equal parts, a one per cent solution of 
carbolic acid or a calamine lotion. A weak tar preparation, 
10 to 20 minims of oil of cade to the ounce of vaseline is 
useful for the chronic dry form of eczema. In the acute stage 
of facial eczema a calamine lotion is the best application (zinc 
oxide, 4 drachms, powdered calamine and boric acid, a drachm 
of each; glycerine, one half to one drachm; three ounces each 
of rose-water and lime-water. When there is much itching ten 
to fifteen minims of carbolic acid may be added). An ointment 



DISEASES OF THE SKIN 273 

containing twenty grains each of calamine, zinc oxide and boric 
acid may be used in the subsiding stage of the inflammation. 
In order to get the best results from an ointment it is sometimes 
necessary to apply the same on pieces of soft linen and bind 
tbem to the affected part with a bandage or a mask. Scratching 
must be inhibited by fastening the arms with appropriate 
restraining measures. Dusting powders are most useful in cases 
in which the trunk and buttocks are affected, and in vesicular 
eczema. A satisfactory formula is equal parts of zinc oxide, 
boric acid and starch. 

Belladonna is an excellent remedy for the acute hyperemic 
stage of eczema, promptly relieving the congestion and itching. 
In vesicular eczema rhus tox. is the most useful remedy. When 
pustules form hepar sulph. is indicated. Constitutional rem- 
edies like calcarea carb., graphites and sulphur should be studied 
in conjunction with the case. Thyroid extract in small doses 
has frequently proven beneficial in the chronic type of eczema. 

ERYTHEMA SCARLATINOIDES. 

The clinical importance of this form of erythema rests upon 
its superficial resemblance to scarlet fever. Although the 
majority of cases are mild and evanescent in character, still 
there are such in which the entire body is covered with a rash 
in association with fever and constitutional symptoms. 

The etiology is evidently a toxemia which may be of in- 
testinal origin or due to idiosyncrasy to certain foods. Eating 
certain food (shell-fish) or tainted meat may give rise to an 
attack. It is sometimes associated with certain infectious 
diseases and with sepsis. Certain drugs, notably mercury, the 
salicylates, quinine and belladonna may produce a similar 
eruption. One of the characteristics of erythema scarlatinoides 
is its tendency to recur. 

The eruption usually appears suddenly, although it may be 

preceded by headache, malaise and fever. The lesions are 

mostly confined to the face, neck, trunk and extremities. The 
19 



274 DISEASES OF CHILDEEN 

rash is usually composed of punctate macules which coalesce 
and give the skin a uniform scarlet color or it may be diffuse 
in character. When the rash is confined to the trunk and 
extremities it is very difficult to distinguish from scarlet fever. 
Usually, however, the eruption quickly fades, leaving none of 
the grave symptoms attending scarlet fever. Burning and 
itching may be annoying symptoms. Desquamation is marked 
in most cases and recurrences are common. 

The differentiation from scarlatina rests upon the absence of 
exposure to contagion; the less general distribution of the rash 
and absence of strawberry tongue, sore throat and adenopathy ; 
absence of albuminuria. Desquamation occurs earlier and does 
not persist as long as in scarlet fever. 

FURUNCULOSIS; BOILS. 

A furunculus, or boil, is an acute, deep-seated, circumscribed 
inflammation originating in a hair follicle or sebaceous gland 
and terminating in necrosis of these structures and surrounding 
connective tissue. The cause is infection with the staphylo- 
coccus pyogenes aureus. 

Symptoms. — In certain infants with malnutrition, boils may 
become a very serious complication. They develop in great 
numbers, especially on the head. They are found chiefly on the 
scalp but may also develop on the face, shoulders and buttocks. 
The majority of furuncles are small but in some instances 
fairly large abscesses develop. While the staphylococcus is the 
exciting cause, still it appears that there is a predisposition in 
these infants which makes them such a favorable soil for this 
organism. Overfeeding with sugar has been mentioned as 
a cause as well as a latent tubercular infection. 

In older children, furunculosis frequently accompanies or 
follows an attack of scabies or pediculosis. This will be readily 
understood by recognizing how irritated and inflamed the skin 
becomes as a result of the incessant scratching accompanying 
these parasitic diseases, thus inviting the entrance of pyogenic 



DISEASES OF THE SKIN" 275 

organisms. Improper and tight clothing, irritating soaps, 
poultices, and the too lavish use of strong antiseptic lotions may 
be contributing factors. 

Treatment. — Constitutional as well as local treatment is 
necessary in these cases. If there has been an excess of sugar 
in the diet this should be reduced and cod liver oil should be 
given. Orange juice should also be introduced into the diet. 

Hepar sulph. is the best remedy not only for this condi- 
tion, but also for all pustular dermatoses. An autogenous 
vaccine may be resorted to in stubborn cases resisting the usual 
forms of treatment. 

Local treatment consists in incising the lesions as soon as 
pus has formed and washing the affected area with a weak 
solution (1 to 4000) of bichlorid of mercury to prevent spread- 
ing the infection. A dressing of 1 per cent Lysol may then 
be applied. As soon as a new lesion is discovered it should 
be touched with tincture of iodine with the hope of aborting 
the same. 

IMPETIGO CONTAGIOSA. 

Impetigo contagiosa is an acute contagious dermatitis, 
characterized by the formation of superficial, circular or oval 
vesico-pustules or blebs, which rapidly form yellowish crusts. 
The exciting cause is the staphylococcus aureus. 

Symptoms. — Except in isolated cases, occurring in infants, 
no constitutional symptoms precede or accompany an attack. 
When present, however, they give rise to submaxillary and 
pre-aural adenopathy, together with moderate fever. The 
lesions are usually seen upon the face and hands. Where the 
fingers become involved the lesions are situated about the 
tissues surrounding the nails. Exceptionally, lesions are found 
on the trunks and extremities. 

The lesions at first are minute vesicles, later increasing in 
diameter, becoming vesico-pustules. Their contents are sero- 
purulent. Desiccation rapidly occurs, leaving brownish spots, 



276 DISEASES OF CHILDREN 

which soon disappear. The attack lasts about a week, fresh 
crops appearing daily. Occasionally lesions rupture and 
coalesce, giving a honeycomb appearance to the group; under 
such conditions itching is a prominent feature. 

In young infants and in the newborn impetigo, instead of 
manifesting itself as a pustular affection, presents the clinical 
manifestations of pemphigus. This disease, occurring in the 
newborn, is, therefore, known as pemphigus neonatorum,, or 
impetigo contagiosa bullosa. It must not, however, be confused 
with sepsis of the newborn in which severe constitutional symp- 
toms accompany the skin lesions. 

Diagnosis. — Impetigo contagiosa may be mistaken for im- 
petigo simplex, varicella, the pustular type of eczema, ecthyma, 
and pemphigus. 

Varicella is differentiated by the presence of fine, pearl-like 
vesicles which appear in crops, and which in some instances 
leave cicatrices. Varicella is occasionally accompanied with 
grave constitutional symptoms. Pustular eczema may suggest 
impetigo simplex, although an eczema invariably produces more 
infiltration and more subjective symptoms. In eczema the 
lesions, although pustular, are deeper, and surrounded by an 
inflammatory areola. The lesions are found upon the legs, 
regions rarely attacked in impetigo contagiosa. Ecthyma is a 
disease of adult life. 

Pemphigus is rarely met with in infants and children. The 
lesions are blebs. Constitutional symptoms are present. The 
resemblance of impetigo in the newborn to pemphigus is only 
superficial. In pemphigus the bullae are larger, are distended 
with fluid and appear in crops. 

Treatment. — Warm baths should be given morning and 
evening. Crusts, if adherent, may be removed by soaking with 
olive oil. A mild antiseptic local application such as the 
ammoniated mercury, ten grains to the ounce of vaseline, will 
cure the majority of cases promptly. In young infants a 
calamine lotion containing one-half of one per cent carbolic acid 



DISEASES OF THE SKIN" 271 

is preferable to an ointment. Hepar sulph. may be re- 
quired to help eradicate the condition. 

URTICARIA; HIVES. 

Urticaria is an inflammatory cutaneous affection character- 
ized by the appearance of evanescent pinkish elevations (wheals) 
which are accompanied by itching and other sensory dis- 
turbances. 

Etiology. — Hives arise from causes that are both internal 
and external. Certain seasons are, in a measure, responsible 
for their outbreak; they are especially apt to appear in the 
spring and fall. The majority of cases occurring in children 
may be traced directly to some gastro-intestinal derangement. 
The condition is most likely one of idiosyncrasy to some food 
protein. Constipation, diarrhea, worms, and acute or chronic 
indigestion may occasionally be responsible. Improper clothing, 
low or high temperature, and the bites or sting of insects may 
be exciting causes. 

Symptoms. — The lesion of urticaria is a wheal. This begins 
as a red, slightly elevated spot which enlarges, the centre be- 
coming paler in color. In shape it is round or oval, frequently 
changing its size and locality, appearing from time to time upon 
different portions of the body. The lesions are particularly 
evanescent; they may last a few hours or but a few minutes, 
leaving behind no trace of their former presence. Rarely they 
persist for days ; occasionally they coalesce and attain consider- 
able dimensions. Their favorite seats are the extremities and 
buttocks, although they may appear on any portion of the skin 
or mucous membrane. Their outbreak is invariably attended 
with intolerable burning and itching, and a slight degree of 
fever. An attack may be acute or chronic. The acute attack is 
usually attended with gastric derangement, headache and slight 
fever. The eruption appears and disappears quickly, leaving no 
trace save a few scratch-marks, resulting from the itching. The 
chronic type may last for weeks or months. In young children 



278 DISEASES OF CHILDREN 

papules and vesicular lesions are frequently associated with the 
wheals. The latter are of an evanescent character but the 
former lesions are more persistent and so they may not be 
suspected of being due to the same etiological factor. The 
papular form is called lichen urticatus and is most frequently 
seen on the arms and legs. Another form seen in children is 
urticaria pigmentosa in which a pigmented spot persists after 
the disappearance of the wheals. 

Urticaria papulosa, or lichen urticatus is a skin affection 
very common in childhood. It is characterized by the appear- 
ance of small, discrete, round papules — often beginning as a 
wheal, but persisting as an itchy eruption. A small vesicle often 
surmounts the papule. They are mostly confined to the 
extremities. 

Diagnosis. — The character of the wheals, their evanescence 
and the presence of intolerable itching and tingling, are suffi- 
cient to establish the diagnosis. Dermatographism is also usually 
present and irritation of the skin, such as scratching, as a rule 
results in the appearance of a wheal at the site irritated. 

Treatment. — Diet is of first importance in the treatment 
of urticaria. When directly traceable to a certain kind of food 
this article should be excluded from the diet. In some instances 
we may be able to determine the offending food by means of the 
cutaneous tests with the various food proteins especially pre- 
pared for this purpose. Constipation or diarrhea, if present, 
must be corrected. During an acute attack a saline purgative 
should be administered. Locally it may become necessary to 
allay the itching by applying a weak solution of carbolic acid,, 
one-half of a drachm to eight ounces of water, or hot water to 
which has been added a little vinegar. 

Belladonna may be administered early in the attack for the 
acute symptoms. 

Urtica wrens is indicated when itching, burning and tingling 
are prominent symptoms. It is indeed almost a specific. Apis 
is also frequently prescribed. 



DISEASES OF THE SKIN 279 

In the chronic form hepar sulph. 3x trit. has given me 
excellent results in a number of cases. 



VEGETABLE PARASITIC DISEASES; TINEA. 

The term tinea trichophytina is employed to designate a 
group of skin diseases due to a fungus growth. The body 
surface or the hairy scalp may be the seat of the lesions. Owing 
to the circular outline assumed by the patches of involved skin, 
tinea is commonly known as ring-worm. 

TINEA TONSURANS ; RINGWORM OF THE SCALP. 

Tinea tonsurans is a highly contagious vegetable parasitic 
disease of the scalp, characterized by the presence of one or 
several bald spots, covered with scales and containing short 
broken-off hairs. 

Symptoms. — Following a period of incubation, variously 
estimated at from three to five days, erythematous areas about 
the size of a twenty-five-cent-piece appear. They are covered 
with grayish scales, and are accompanied by slight itching ; they 
enlarge peripherally and may coalesce. The hairs of these parts 
become lustreless and break off. In some cases the scalp is 
entirely denuded, making a complete bald spot. Occasionally 
vesicles and pustules form, and a certain amount of suppuration 
results. Resolution may take place in one area, while the 
disease is active in another. The general health is rarely 
affected. 

Tinea tonsurans is due to the presence and growth of the tri- 
chophyton fungus. It is highly contagious, being transmissible 
to the lower animals, from whom it may be contracted. It is 
often endemic in asylums and hospitals, or where a number of 
children are congregated. 

Pathology. — As a rule, only the superficial parts of the 
epidermis and hair are attacked in children. Microscopically, 
mycelia and spores are seen. The hairs become brittle, but ? as 



280 DISEASES OF CHILDREN 

a rule, baldness is not permanent. The hairs usually return 
to their normal state. 

Diagnosis. — Ring worm of the scalp may be mistaken for 
alopecia areata and squamous eczema. 

Alopecia areata. — Baldness in alopecia areata is complete. 
The condition develops quickly and is more common in adults 
than in children. The patches are entirely devoid of hair and 
the affected skin has a white, atrophic appearance. 

Prognosis. — Isolated cases, if seen early and subjected to 
proper treatment, are curable within a few weeks. An epidemic 
occurring where a number of children dwell together is hard to 
eradicate. In the majority of cases a few months will be 
required to efface the disease, and it must be remembered that 
relapses are common. 

Treatment. — Prophylaxis is of the greatest importance. 
Children afflicted with tinea tonsurans should not be permitted 
to come in close contact with others. The possibility of con- 
tracting the affliction from domestic animals should be borne in 
mind. The general health of the child should be looked after 
and a constitutional remedy should be administered when there 
is anemia or malnutrition. When secondary infection with 
suppuration has set in Jiepar sulph. is indicated. Parasiticides 
are necessary to eradicate the fungus growth. Before these can 
be satisfactorily applied the scalp must first be suitably prepared. 
The hair about the patch and for some space surrounding it, 
should be cut and the scalp closely shaven. The short hairs 
should be removed by means of forceps. Scales and crusts, if 
present, are removed by scrubbing vigorously with a solution 
of green soap. Where the patches are extensive, it is necessary 
to shave the entire scalp. L>epilation of the diseased hairs is 
tedious and often unsatisfactory. As a rule the hair is brittle 
and breaks off, not coming out entirely. The process, however, 
should be practiced daily. Locally the best application is 
bichloride of mercury, one to one thousand; it should be 
discontinued if it excites active inflammation. Carbolic acid, 



DISEASES OF THE SKIN 281 

one drachm to one pint of water, is frequently efficacious. 
Among other agents are sulphur ointment, a five per cent 
ointment of the oleate of murcury, and equal parts of the oil 
of cade and olive oil. After an apparent cure, the scalp should 
be treated every other day, to prevent the possibility of a relapse. 

TINEA CIRCINATA; RINGWORM. 

Tinea circinata is a highly contagious vegetable parasitic 
disease of the skin, caused by the trichophyton fungus. It is 
characterized by the presence of annular patches of varying size 
and character, occurring upon any part of the body surface. 
Ringworm is more common in children than in adults probably 
because the child's skin is more readily attacked by the fungus 
and because the possibilities for infection are greater. The 
fungus may be contracted from another child or from a domestic 
pet, most commonly the cat. 

Symptoms. — Ringworm of the scalp and ringworm of the 
body are often found co-existing. Minute, irregular-shaped 
spots of a reddish-brown color indicate the commencement of 
ringworm of the body. Later a distinct circular patch is seen, 
which heals in the center and spreads peripherally. Around the 
margin of each patch small papules and papulo-vesicles are 
seen. Scaling is a distinct feature. The typical ringworm is 
usually about the size of a dime, and it stands out prominently 
from the surrounding skin. In some instances the rings join 
together. Any part of the body may become affected, although 
the face and hands are most frequently attacked. Next to these 
localities, the axillary and inguinal folds are involved. 

Diagnosis. — Tinea circinata may be mistaken for seborrhea 
and eczema squamosum. In seborrhea the scales are greasy 
and the fungus is absent. In eczema there is infiltration of the 
skin, more itching and the characteristic annular formation of 
the lesion is absent. Should any doubt exist as to the diagnosis, 
a microscopical examination will usually detect the fungus. 

Treatment. — The fungus can be destroyed by scrubbing the 



282 DISEASES OF CHILDREN 

lesions every morning and evening with green soap and hot 
water, and afterwards applying a solution of sodium hyposul- 
phite (drachm to the ounce) or painting the patch with a weak 
iodine tincture. In obstinate cases it may be necessary to re- 
sort to a 25 per cent aqueous solution of ichthyol. Care must 
be observed in using ichthyol, since it is likely to provoke an 
acute dermatitis. 

ANIMAL PARASITES. 

The animal parasites with which children are most likely to 
be infested are pediculi, or lice, and the itch mite, or scabies. 

Pediculosis: Lice. — Pediculosis is a contagious animal 
parasitic affection in which the body is infested with lice. 
These set up both primary and secondary lesions. 

Symptoms. — In infants and children pediculosis is, as a 
rule, confined to the scalp. The uncleanly are mostly attacked. 
These parasites attack the scalp, causing much itching and 
scratching; escape of serum and purulent fluid occurs, forming 
crusts. The hairs become matted together; scratch-marks, 
pustules, excoriations and furunculi contribute to this unsightly 
condition. The cervical glands become secondarily enlarged. 

Occasionally an eczematous condition of the scalp accompan- 
ies pediculus capitis. Pediculi are found both upon the scalp 
and the hairs. The nits are usually upon the hairs. The term 
plica polonica has been applied to an aggravated state of lousi- 
ness, where living and dead lice and their nits have matted the 
hairs together, an offensive odor arising from the decomposing 
pus and crusts. Severe inroads are in some instances made 
upon the general health, traceable to the annoyance coincident 
to incessant itching and scratching. 

Diagnosis. — The detection of pediculi and their nits, to- 
gether with their resulting secondary changes, will at once estab- 
lish the diagnosis. 

Treatment. — Kerosene oil is the best remedy with which to 
kill the parasites and their ova. The kerosene, or petroleum 



DISEASES OF THE SKIN 283 

oil may be mixed with olive oil and some balsam of Peru added. 
This mixture is less irritating and more efficacious than the 
plain oil. A good formula is four ounces of petroleum, two 
ounces of olive oil and half an ounce of balsam of Peru. It 
should be applied freely, and the scalp subsequently covered 
with a muslin or oil-silk cap. On the following day the head 
should be shampoed with soap and water followed by the lib- 
eral application of diluted vinegar, which dissolves the nits. 
This procedure may have to be repeated a number of times 
before a cure is completed. Should eczema of the scalp be 
present it must receive suitable treatment. 

Scabies; Itch. — Scabies is a contagious animal parasitic 
disease of the skin, in which acarus scabiei is the exciting cause 
of the lesions. 

The male itch-mite rarely burrows beneath the epidermis. 
The female, however, penetrates deeply, making minute tun- 
nels, which serve as a habitat. The acarus selects those regions 
where the skin is tender, as the axillary and interdigital spaces, 
producing papules, vesicles, pustules, bulla?, wheals, infiltra- 
tions, furuncles and crusts. Scabies is spread by direct con- 
tact and is chiefly encountered among the poorer classes who 
live in overcrowded households and under conditions making 
personal cleanliness a difficult matter. 

Pathology. — Inflammation of the papillary layer of the skin 
results from the presence of the acarus. Itching, which is 
usually intense, is a very distressing symptom. It is particu- 
larly severe during the sleeping hours, since the female acarus 
is most active when the patient is protected by the warmth of 
the bed-coverings. 

Diagnosis. — The diagnosis of scabies should not be attended 
with any difficulty. However, cases in which secondary lesions 
such as papules and pustules and eczematous patches have 
resulted from scratching and infection are often mistaken for 
some other more serious condition. The presence of character- 
istic lesions, situated in the interdigital and other favorite 



284 DISEASES OF CHILDREN 

regions, associated with marked and distressing itching, should 
lead one to a positive opinion. 

Pediculosis causes itching only of the parts attacked. Itching 
as a symptom of scabies is frequently referred to parts unat- 
tacked. In pediculosis the scratch marks are mainly confined 
to the shoulders, chest and waist-line and the itching is usually 
worse during the daytime. In itch, on the other hand, the 
itching is worse at night, and the hands, the flexor surface of 
the wrists and arms, the axillary folds and the genitals are 
affected. This characteristic distribution as well as the progres- 
sive character of the affection and presence of the burrows of 
the mites also differentiates itch from eczema. 

Treatment. — The best parasiticide against the itch-mite is 
the balsam of Peru either used alone or in combination with 
a sulphur ointment. A drachm each of balsam of Peru and 
sublimated sulphur to three ounces of vaseline makes an efficient 
formula. The affected parts should be scrubbed with warm 
water and tincture of green soap after which the ointment 
should be thoroughly rubbed in. The treatment should be 
carried out night and morning for three days, after which a 
complete change of clothing and bed-clothes is to be made and 
the child given a hot bath. The clothes should be baked before 
putting them into the wash. 

Dermatitis, if excited, may be controlled by discontinuing the 
use of the ointment and instituting appropriate treatment. 



CHAPTER XIII. 

DISEASES OF THE BLOOD. 

The total amount of blood in the body of a child is somewhat 
less in proportion to the body weight than in an adult. Like- 
wise the specific gravity is lower, the average being 1050 
as compared to 1055 in adults. It bears a close relation- 
ship to the amount of hemoglobin, which is also proportionately 
low during infancy and early childhood. In the new-born, how- 
ever, the hemoglobin percentage is high, but thereafter it rapidly 
falls, ranging between 55 and 85 per cent. Under ordinary 
circumstances 60 per cent may be considered the minimum for 
a healthy infant. 

The red corpuscles, or erythrocytes, are most numerous at 
birth. Even during the period of infancy they remain relatively 
more numerous than in childhood and in adult life. They 
gradually decrease from six to six and a half million per cubic 
millimeter at birth to four and a half to five and a half million 
in early childhood, and the normal standard of five million is 
attained later in childhood. Fluctuations in the number of 
erythrocytes is, however, more common than in adults; even 
daily variations can be observed. 

The form of the red corpuscle is variable in the new-born, 
and nucleated corpuscles (normoblasts) may be seen. The 
corpuscles also readily lose their hemoglobin, forming the so- 
called shadows of Silbermann. Variations in form, and the 
occurrence of nucleated red corpuscles later in childhood, are, 
however, always pathological, but these changes are observed in 
any severe type of anemia and are not of as serious significance 
as in adults. 

The leucocytes are relatively more numerous than in adults. 
In the new-born a leucocytosis is present. According to Hayem 
there may be as many as 18,000 leucocytes to the cubic milli- 



286 DISEASES OF CHILDREN 

meter, but they fluctuate widely under slight influences, such 
as diet. A leucocyte count of from 10,000 to 12,000 during 
infancy may be considered normal. In childhood the number 
varies between 8,000 and 10,000, being slightly higher than in 
the adult. 

The various forms of leucocytes are: (a) Lymphocytes, or 
small mononuclear cells, which are believed to originate from 
the lymphoid tissue. They are about the size of a red blood 
corpuscle and contain a single large nucleus which almost 
completely fills the cell. A narrow rim of strongly basophile, 
homogeneous or coarsely reticular cytoplasm surrounds the 
nucleus. During infancy the lymphocytes are the predom- 
inating leucocyte representing from 50 to 60 per cent of the 
differential count. During childhood there is a gradual decrease 
of the lymphocytes with a corresponding increase of polynuclear 
leucocytes. The lymphocytes are most markedly increased in 
lymphatic leukemia. An actual increase is also noted in many 
cases of rickets, and a physiological increase occurs after feed- 
ing. The lymphocytes are also relatively increased in tuber- 
culosis. An actual lymphocytosis is observed in the early stage 
of whooping-cough. 

(b) Large mononuclear cells, derived from the bone marrow 
and spleen. They are much larger than the preceding form and 
are not so numerous, constituting about 6 per cent of the 
different forms. In infancy the percentage is higher, while in 
the fetus they are most numerous. The nucleus is vesicular, 
does not stain as deeply as that of the small leucocyte, and at 
times has an indented, horse-shoe appearance, believed to be 
a stage of transition to the polynuclear form. The protoplasm 
is faintly basophile and may show a fine reticulum. On account 
of their light staining they are often spoken of as "hyaline 
cells." These cells are increased, as a rule, in conjunction with 
the lymphocytes, but they are especially increased in the so- 
called pseudo-leukemia of von Jaksch and in malarial 
fever. In malarial infection there is not only an absolute 



DISEASES OF THE BLOOD 287 

increase in the large mononuclear cells, but also a relative 
increase over the small lymphocytes. They are also increased 
in measles, and in syphilis, tuberculosis and in typhoid fever, 
when these diseases become well established. A differential 
count of these cells, therefore, plays an important role in the 
diagnosis of obscure febrile affections. In the cases of malarial 
infection without much fever and without quinine history the 
polynuclears are diminished and the large lymphocytes much 
increased (Krauss, Jour. Amer. Med. Ass., Oct. 22, 1904). 
This also holds good in recent cases. As some difficulty may 
arise in distinguishing between a large and a small lymphocyte, 
Krauss gives the following rule: "Class all cells the size of a 
polynuclear cell as small unless the protoplasmic margin is 
relatively large, and contains scattered neutrophile granulations, 
which stamps the cell as a large one." 

(c) Polynuclear leucocytes, or neutrophiles. They are 
large leucocytes with several nuclei connected by threads, there- 
fore they are also called "polymorphonuclear." The nucleus 
takes the basophile stain while the protoplasm is neutrophile 
and contains distinct granulations. They are the most num- 
erous* of all leucocytes, excepting in infancy, constituting from 
60 to 65 per cent in children and as high as 70 per cent in 
adults. In the new-born the polynuclear leucocytes represent 
about 63 per cent of the white corpuscles and they rise to 70 
per cent in the first forty-eight hours. After that a rapid 
destruction of these corpuscles takes place and they fall to about 
35 per cent. They are rapidly increased in infectious diseases, 
acting as phagocytes. These cells form the pus cells in all active 
suppurative processes. 

(d) Eosinophile leucocytes are large, round, polynuclear 
cells containing coarse, granular bodies which stain deeply 
with eosin. Their affinity for this stain gives them their name. 
Normally but 2 to 4 per cent are encountered, but in leukemia 
there is both a relative and an absolute increase. An eosinophilia 
is observed in children infested with intestinal worms and is 
a fairly constant finding in asthma. 



288 DISEASES OF CHILDREN 

(e) Myelocytes, or Markzellen, being so named from their 
origin in the medullary cavity of long bones. They are never 
found in the blood under normal conditions. They are several 
times larger than a red blood corpuscle, and have a single 
nucleus that stains but faintly. The protoplasm contains neu- 
trophil granulations. They are found in spleno-medullary 
leukemia in conjunction with an increase of eosinophils, and 
in severe secondary anemias. 

(f) Mast-cells are variously sized leucocytes, either mono- 
or polynuclear, their protoplasm containing strongly basophile 
granules. They are found in a small proportion in normal 
blood, but in leukemia, and especially in the secondary anemias 
of childhood, they are considerably increased. 

The following laboratory methods are essential for a proper 
clinical study of the blood : 

1. The determination of the 'percentage of hemoglobin. This 
may be performed roughly with the use of the Tallquist scale. 
A drop of blood is collected upon a piece of unglazed paper and 
its color compared with the scale of the Tallquist hemoglo- 
binometer. The results are only approximate but the bleeding 
time can be estimated at the same time that the color of the 
blood is noted. A more accurate instrument for careful clinical 
work is the Dare hemoglobinometer. With this instrument 
undiluted blood is used, the blood being allowed to flow into 
a small chamber between two plates of glass. The color of 
this film of blood is then compared with a color scale made from 
a circular disc of colored glass. The scale is turned until the 
colors correspond and the percentage of hemoglobin can then 
be read off at the side of the instrument. 

2. The determination of the number of red corpuscles. For 
the purpose of counting the red corpuscles the hemocytometer 
of Thoma-Ziess is used. This instrument is supplied with a 
pipette graduated to hold one cubic millimeter of blood and one 
hundred millimeters of diluting fluid. A one to two hundred 
dilution is usually employed excepting in severe types of anemia. 



DISEASES OF THE BLOOD 289 

The blood is thoroughly mixt with a solution corresponding to 
the blood serum in density (Gower's solution) and a drop is 
then placed upon the counting chamber which is ruled off into 
squares so that the corpuscles can be readily counted and the 
number in a cubic millimeter accurately estimated. When a 
one to two hundred dilution of the blood has been made five 
large squares of the counting chamber, each containing sixteen 
smaller squares, are counted and four ciphers added to the total 
number of cells counted. The result represents the number of 
red corpuscles in one cubic millimeter of blood. 

3. The determination of the white corpuscles is carried out 
on the same principle, but, as they are less numerous, a larger 
pipette, giving a dilution of one to ten, is employed. Usually 
a one to twenty dilution is used to facilitate counting the 
leucocytes. With a one to twenty dilution the number of 
leucocytes in a square millimeter are counted and this number 
is multiplied by two hundred. The result is the number of 
leucocytes in one cubic millimeter of blood. A 3 per cent 
solution of acetic acid is used as a diluting fluid. This destroys 
the erythrocytes and renders the leucocytes more conspicuous. 

4. The differential count of the leucocytes is performed by 
preparing a thin film of blood, and staining the same with 
Wright's stain so that the various types of white corpuscles can 
be identified. Two hundred leucocytes are counted and classi- 
fied and the percentage of the different types estimated. The 
film is best made by collecting a small drop of blood on a square 
cover-glass, covering the same with another cover-glass, and then 
carefully drawing the slips apart after the blood droplet has run 
out into a thin film. The spreads are dried and then stained 
with Wright's stain. 

5. The microscopical appearance of a fresh drop of blood is of 
great importance for diagnostic purposes. The shape and size 
of the red corpuscles, the absence of rouleaux formation, the 
presence of nucleated red corpuscles, the presence of parasites 
(Plasmodium of malaria), must all be taken into consideration. 

20 



290 DISEASES OF CHILDREN 

6. The Specific gravity is obtained by floating a drop of blood 
in a mixture of chloroform and benzol of 1050 to 1060» specific 
gravity. A drop of blood is allowed to fall into a test tube 
containing ten cubic centimeters of the fluid, and, according as 
it drops to the bottom or floats on the surface, chloroform 
or benzol is added. When it remains suspended in the fluid 
the specific gravity of the latter is taken, it corresponding to 
the specific gravity of the blood drop. For a fuller description 
of the instruments, technique and methods of blood study the 
standard works on Clinical Diagnosis should be consulted. 

ANEMIA. 

Clinically two varieties of anemia are encountered, namely 
'primary and secondary. The latter form is far more common 
and is usually less serious in its clinical aspect than a primary 
anemia. Primary anemia is a manifestation of a developmental 
defect in the blood making organs as in aplastic anemia, or of 
some unknown etiological factor which may either cause an 
increased destruction of the blood elements or interfere with 
the formation of normal, mature blood elements which are 
necessary to replace those destroyed in the spleen and tissues. 
Secondary anemia is a reduction in the amount of blood from 
hemorrhage or an impoverishment of the blood resulting from 
malnutrition and unhygienic surroundings. It frequently 
develops as a sequela of an acute infectious disease and is 
prominently associated with tuberculosis, rheumatism and 
syphilis. Chronic intestinal indigestion and intestinal parasites 
may be the cause of a secondary anemia of severe type. A diet 
deficient in iron and other mineral salts and perhaps vitamines 
may also lead to a secondary anemia. 

There is a strong tendency for the blood to revert to the 
embryonic type whenever an increased effort to replace the blood 
elements becomes necessary and so it is common to find nucleated 
red corpuscles and myelocytes in the infantile anemias. En- 
largement of the spleen is also frequently encountered as well as 



DISEASES OF THE BLOOD 291 

a leucocytosis. In rickets, for example, various types of anemia 
may be encountered, ranging in severity from a slight reduction 
in the number of red corpuscles and the percentage of hemo- 
globin to a severe type with pronounced pallor, reduction of red 
cells, the presence of nucleated red corpuscles, a leucocytosis 
with myelocytes and enlargement of the spleen. Clinically the 
majority of cases of anemia in infancy and childhood are 
secondary and there is usually a nutritional disturbance, a 
history of improper feeding or a disease like rickets, scurvy, 
tuberculosis, etc. to account for the anemia. There is a rare form 
of anemia occasionally encountered in infants which is evidently 
a primary disturbance in the blood making organs; this is 
known as pseudo-leukemia of von Jalcsch. 

The following clinical classification for the secondary anemias 
is given by Morse : 

Mild anemia, characterized by trifling reduction in the hemo- 
globin percentage and number of erythrocytes and absence of 
abnormal changes in the blood elements. 

Severe anemia with pronounced diminution of hemoglobin 
and erythrocytes, together with changes in the size and shape of 
the corpuscles and the presence of normoblasts, or nucleated 
red blood corpuscles. 

Anemias with leucocytosis are usually associated with more 
pronounced reduction in hemoglobin and red corpuscles than 
anemias without leucocytosis (Da Costa). Normoblasts and 
deformities in size and shape of the erythrocytes are encountered 
in these cases. 

CHLOROSIS. 

Chlorosis is a form of primary anemia which is seen most 
frequently in girls at the time of puberty, but it is not neces- 
sarily confined to this period of life nor to the female sex. 
Of the etiology nothing positive is known excepting that unhy- 
gienic surroundings, improper or insufficient food, lack of fresh 
air and sunshine, emotional disturbances and obstinate constipa- 



292 DISEASES OF CHILDREN 

tion are frequently intimately associated with the development of 
chlorosis. The heart and larger blood-vessels have been demon- 
strated by Virchow as under-developed in many instances. 

The symptoms of chlorosis may make their appearance 
rapidly, or the disease may not be suspected for a long time 
until pallor and the characteristic greenish tint of the skin, 
on acount of which it is popularly known as "green sickness," 
give a clue to the existing ill-health. The child complains of 
headache, and displays an aversion to mental or physical 
exertion of any kind. Exercise brings on dyspnea and pal- 
pitation, while the headache and languor are responsible for the 
indifference to both work and play. 

The appetite is poor, and in many instances becomes per- 
verted, so that the patient craves chalk, slate-pencils, coffee- 
beans, etc., which are apparently enjoyed. Indigestion and 
constipation are troublesome symptoms, and their correction 
materially hastens the cure. 

In young girls, menstrual derangements are inseparably 
associated with chlorosis. Thus, scanty menstruation or 
amenorrhea are almost invariably encountered in these cases; 
likewise, dysmenorrhea and leucorrhea are common. Improve- 
ment in the chlorotic state results in prompt improvement of 
these conditions. 

The red corpuscles are but slightly decreased in number, but 
there is a pronounced deficiency of hemoglobin, giving the 
individual corpuscles a noticeably pallid appearance. The 
disturbance is, therefore, primarily in the blood-making organs 
which are incapable of making corpuscles of a normal hemo- 
globin content. 

Edema tends to develop about the ankle joints, and many 
patients present a puffy, fat appearance, indicating a hydremic 
state, with sluggish return circulation. The degree of anemia 
can be roughly estimated by the appearance of the palpebral 
conjunctiva, the lips and the matrix of the nails, but in order 
to follow the progress of the case accurately we should make 



DISEASES OF THE BLOOD 293 

regular hemoglobin estimations with the Dare hemoglo- 
binometer. 

The prognosis of chlorosis is favorable, and it usually 
responds promptly to treatment, although there is a liability to 
relapses. The chlorotic child is probably more susceptible to 
tubercular infection than a normal individual and should there- 
fore be carefully protected against exposure to this disease. 

PROGRESSIVE PERNICIOUS ANEMIA. 

This form of primary anemia is a rare disease, and is more 
seldom seen in children than in adults. The etiology is 
obscure. Birch-Hirschfeld advances the infectious theory, 
owing to the presence of tissue destruction and retardation of 
blood coagulation ; others hold to the theory of increased hemo- 
lysis, and again others to decreased hemogenesis. Stengel 
{Medical News, Oct. 20, 1900) expresses the view that per- 
nicious anemia is undoubtedly a disease resulting from the 
rapid destruction of red blood corpuscles, for the compensation 
of which the blood-making functions prove inadequate; and, 
further, that the source of the hemolytic agents is the gastro- 
intestinal tract. 

The anemia resulting from intestinal parasites is very difficult 
to distinguish from pernicious anemia, showing the great 
liability for error and the difficulty with which a study of the 
disease is beset, as so many factors are capable of inducing 
pronounced anemia. In eighteen cases seen by Osier (Amer. 
Text-Book of Practice) there was no appreciable cause for the 
disease. Henoch (Vorlesungen u Kinderkrankh.) saw two 
children in the same family die of this disease, no cause being 
ascertainable. Ewing thinks that any case of pronounced, 
progressively-increasing anemia in which the blood contains 
megaloblasts and a considerable proportion of megalocytes with 
increased hemoglobin, while the lymphoid marrow shows marked 
hyperplasia of peculiar type, should be considered one of per- 
nicious anemia, regardless of the immediate exciting cause. 



294 DISEASES OF CHILDREN 

Even in the gravest secondary anemias these changes are rare, 
but in early life the changes in the blood are so pronounced in 
anemia that they are difficult to interpret. The frequency of 
pernicious anemia in childhood, therefore, is still a question. 

The symptoms are those of a gradually increasing anemia. 
Loss of flesh may be absent. Edema and hemorrhage may 
supervene. The skin assumes a characteristic lemon-yellow 
tint. Anorexia, vomiting and other digestive disorders accom- 
pany the condition. The patient eventually dies from exhaus- 
tion, although remissions, leading one to believe that the case is 
recovering, frequently occur. The blood changes are the same 
as found in the adult as far as pronounced oligocythemia and 
nucleation and deformities of the erythrocytes are concerned, 
but the blood often fails to show the high color index and the 
prevalence of megaloblasts and of megalocytes that are accepted 
as diagnostic of the disease in adults (Da Costa). 

Treatment. — The hygienic management of cases of anemia 
is of first importance. In chlorosis it is important to overcome 
constipation; this is best accomplished by means of diet and 
enemata. Fruits and fresh vegetables, many of which are rich 
in iron (notably spinach), are very beneficial. For anemia 
in general it may be said that the most nutritious and most 
digestible form of food is to be selected. The digestion is 
usually impaired and an achylia gastrica may be present, for 
which reason it is often desirable to administer digestive 
ferments, such as pepsin or papain, or small doses of dilute 
hydrochloric acid. 

Milk is an ideal food in all forms of anemia, and chlorotic 
subjects may drink of it freely, even between meals. Eggs are 
also very beneficial, being easily digested, and their yolk 
contains a large percentage of iron. There is some risk in using 
raw beef but meat is usually not well digested by these patients 
unless given rare. Beef -juice is better for young children than 
the meat itself. 

Where exhaustion is a prominent symptom, rest instead of 



DISEASES OF THE BLOOD 295 

exercise should be prescribed. Absolute rest in bed, with 
massage and liberal feeding, will accomplish more in such cases 
than exercise, which only adds to the exhaustion and tissue 
breakdown. 

The following remedies are the ones most useful in the 
various forms of anemia: 

Belladonna, — In chlorosis, when there is violent palpitation, 
throbbing headache, great weariness and desire to sleep in the 
afternoon, debility. The symptoms of belladonna are very 
similar to those of ferrum, especially the palpitation, dyspnea 
and rush of blood to the face, alternating with paleness; but 
there is not that intense anemia and persistent debility, gastral- 
gia, vomiting, amenorrhea and anasarca indicating the latter 
remedy. 

Ferrum is seldom of use elsewhere than in chlorosis to which 
it is strictly homeopathic, as indicated by its symptomatology. 
Here it has gained universal reputation, and even its empirical 
use in large doses is frequently of great benefit. ~No doubt 
such remedies as pulsatilla, nux vom. and spigelia owe their 
usefulness in chlorosis to their influence upon the alimentary 
tract, and when they are indicated the use of iron is not always 
necessary for the cure, as sufficient iron should be absorbed 
from the food to supply the blood with all that it requires. 

In pernicious anemia and in the secondary anemias iron is 
of little value as it does not act upon the hematopoietic organs. 
Many preparations of iron are in vogue, each form having its 
ardent advocates. Ferrum reductum in the first decimal trit- 
uration is one of the most reliable preparations ; the oxalate of 
iron finds great favor with many of the British homeopathists 
in chlorosis. Blaud's pill is the best form in which to give 
iron in large doses. 

Graphites. — Chlorosis, tendency to obesity, sluggish circu- 
lation and anemia, with general coldness; delayed or scanty 
menses, obstinate constipation; sad, tearful disposition. 

Natrum mur. — Chlorosis, obstinate cases, fluttering of the 
heart, craving for salt. 



296 DISEASES OF CHILDREN 

Nux vom. — Chlorosis, gastric derangements, constipation, 
irritability, prostration; languid, especially morning on rising 
from bed; perverted appetite. 

Pulsatilla. — Chlorosis, great weakness and sluggishness of 
the circulation, manifesting itself as chilliness ; coldness and 
paleness of face, relief in open air. Anorexia, nausea, palpita- 
tion of the heart and dyspnea, sharp pains about heart 
(compare also spigelia and cactus, both of which are indicated 
by their cardiac symptoms), amenorrhea, leucorrhea; sad 
tearful disposition. 

Other important remedies in chlorosis are cede, c, helonias, 
sepia and sulphur. 

China is a most valuable remedy in anemia developing after 
hemorrhages, chronic diarrhea, long-continued suppuration, 
and in all mild forms of idiopathic anemia as a "tonic," given 
in doses of two to three drops of the tincture, three to four 
times daily. 

Arsenicum corresponds more closely to the pernicious forms 
of anemia than any other remedy, and is also indicated in the 
anemia of malaria and of Bright' s disease. Its indications are 
excessive debility, edema of the ankles and eyelids, cardiac 
weakness and dyspnea, gastric irritability. 

Phosphoric acid and silicea are useful in the anemia of 
debilitating diseases, such as typhoid fever, following well after 
china. 

Mercurius is specific in the anemia of syphilis. 

Kali carb. corresponds to a vitiated state of the blood plasma. 
Farrington refers to its ability to produce anemia, and recom- 
mends it for the blood poverty after severe or protracted 
diseases. The following symptoms are recorded in Hering's 
Condensed Materia Medica: "Vertigo, congestion to head 
with throbbing and humming. Swelling like a bag be- 
tween upper eyelids and eyebrows. Palpitation in spells, 
taking his breath; stitches about heart; weak, irregular pulse. 
Arms go to sleep. Swelling of feet to ankles. Anemia, with 



DISEASES OF THE BLOOD 297 

great debility; skin milk-white; muscles weakened, especially 
the heart." Our claims for the value of this remedy in anemia 
have been substantiated lately by old school therapeutics. 
Denstedt and Rumpf (Therapeutische Mon-atshefte, March, 
1901) demonstrated that in pernicious anemia the blood gave 
a high percentage of water and sodium chlorid and a great 
reduction in the percentage of iron and potash. Accordingly, 
potash salts were administered in several such cases, both by 
mouth and infusion, with marked improvement. It seems that 
the death of the corpuscles depends upon the abstraction of its 
potash, and potash, therefore, has the same specific relationship 
to degenerative changes in the corpuscles that iron has to hemo- 
globin poverty in the corpuscles (chlorosis) and arsenic to the 
stimulation of the blood-making organs. 

LEUKEMIA; PSEUDO-LEUKEMIA; SPLENIC ANEMIA; 
HODGKIN'S DISEASE. 

The varieties of anemia described under the above titles 
present as their most characteristic features permanent leucocy- 
tosis and splenic enlargement. 

Their differentiation presents many points of difficulty, which 
can only be definitely settled by careful hematological exam- 
inations. They are seldom encountered during childhood, 
excepting the form known as anemia infantum pseudoleukemia 
von Jahsch. They all present an unfavorable prognosis. 

Leukemia may affect persons of all ages, but it is rare during 
childhood. Mossa has collected a series of twenty-seven cases 
in children, but he admits that a large number of these were 
undoubtedly not cases of true leukemia. Da Costa collected ten 
cases, in all of which the diagnosis was confirmed by the examin- 
ation of the blood. 

The symptoms are anemia, pronounced pallor, distended 
abdomen, with enlargement of the spleen, and tenderness. The 
lymphatic glands may be principally involved, as in the 
lymphatic variety, or the spleen and marrow, in the spleno- 



298 DISEASES OF CHILDREN 

medullary variety. In the lymphatic variety the lymphocytes 
are markedly increased, sometimes the large, at other times the 
small mononuclear cells predominating. The polynuclear 
cells are relatively decreased. In a case coming under my notice 
the polynuclear cells had almost entirely disappeared from the 
blood, the blood-count giving fi.ve thousand leucocytes, mostly 
lymphocytes. The erythrocytes are diminished and a few 
normoblasts may be present. In the spleno-medullary variety 
there is a relatively small increase in the lymphocytes, but 
myelocytes are found in great numbers in conjunction with an 
increase in the eosinophile cells. 

The disease assumes a progressively downward course, usually 
terminating in general edema, hemorrhages and exhaustion. 
At times it is febrile, simulating an infectious disease, and runs 
an acute course. This is more likely to occur with lymphatic 
than with spleno-medullary leukemia. 

Hodgkins disease presents enlargement of various groups 
of the lymphatics; enlargement of the spleen and liver; fever 
of an intermittent type, and progressive anemia and leucocytosis. 
The leucocytes are only moderately increased in numbers and 
abnormal elements (myelocytes and an increase in eosinophiles) 
are not present. The cervical and axillary glands, or those 
situated near by, are usually the ones first affected, other groups 
eventually becoming implicated. They do not, however, tend 
to break down, this being a strong point of differentiation 
between Hodgkin's disease and tuberculous adentis. The course 
is chronic, and the prognosis is always unfavorable. 

Anemia Infantum Pseudoleukemia von Jaksch is a disease 
of childhood, usually seen before the second year. The etiology 
is obscure. Several cases may occur in the same family. It was 
first described by v. Jaksch, its characteristics being: Occur- 
rence in infancy; oligocythemia and oligochromemia ; per- 
manent leucocytosis ; marked splenic enlargement, and at times 
lymphatic enlargement. The liver is but slightly enlarged, 
a clinical distinction between this disease and leukemia. The 



DISEASES OF THE BLOOD 299 

prognosis is more favorable than in the latter disease, but many 
cases terminate fatally. The term splenic anemia has been 
applied to a class of cases similar in all respects to pseudo- 
leukemia but without a leucocytosis. 

The development of pseudoleukemia is one of progressive 
pallor, failure in general health, digestive disturbances, and at 
times slight pyrexia. The anemia is very noticeable, and 
palpation reveals an enlarged spleen. ~No doubt many cases 
described as pseudoleukemica are in reality a severe type of 
secondary anemia. Such an anemia is at times encountered 
in infants with rickets. 

Treatment. — Homeopathic literature on these affections is 
meagre. Of our writers, Gilchrist enters most extensively into 
the subject in an article upon "Leucocythemia" (Amdt's 
System of Medicine), in which he also reports a case of Dr. 
Gaylord's represented as leukemia, which, however, should be 
classed as a case of anemia infantum pseudoleukemia. The 
patient was an infant of six months, anemic from birth, living 
in a malarial district. There was leucocytosis and splenic 
enlargement. China 2x and an occasional dose of ferrum 
resulted in a cure. Dr. Broadbent (Horn. Review, vol. xxi) 
recommends phosphorus as the most appropriate remedy in 
leukemia. 

Gilchrist believes china and phosphorus to be the most 
closely related remedies to the disease. The old school depends 
upon arsenic in conjunction with iron and cod liver oil 
in leukemia, pseudoleukemia and Hodgkin's disease, although 
no claims for cures are made. The X-ray and radium have 
proven beneficial in Hodgkin's disease. Koplik has used 
ichthyol with some success in leukemia. Owing to its strong 
homeopathic relationship to rickets I should look upon phos- 
phorus as the most appropriate remedy in the so-called "splenic" 
and "pseudoleukemic anemias." 



300 DISEASES OF CHILDREN 

HEMOPHILIA. 

The subjects of hemophilia are commonly known as 
"bleeders," from the tendency to profuse and often uncon- 
trollable hemorrhages which this form of constitution presents. 
The disease is hereditary, and the mode of transmission is a 
clear demonstration of atavism through the female, as hemo- 
philia rarely occurs in females, being transmitted by the 
daughters of bleeders to their male offspring. 

The pathology of hemophilia is not quite clear. In some 
instances it would seem to depend upon an abnormality in the 
walls of the small blood-vessels, and in others upon a delayed 
coagulation of the blood. The pecularity which some cases 
present of only bleeding excessively in certain localities would 
favor the first mentioned explanation. According to Addis the 
cause of the delayed coagulation is a deficiency of prothrombin 
in the blood. A calcium deficiency has also been noted. The 
blood platelets are not diminished but there is a delay in their 
blood-clotting function. 

The diathesis usually develops early in childhood, by the end 
of the first dentition period, when an accidental cut or injury 
first attracts attention to this tendency. Beside the danger of 
hemorrhage from a traumatism or an operation, there is as 
great a one from spontaneous hemorrhage such as epistaxis, 
hematemesis, hemoptysis, hemorrhage from the mouth, intes- 
tines, urethra, etc. Injuries without destruction of continuity 
of the skin are followed by profuse bloody effusions into the 
subcutaneous structures. 

The hemorrhagic diathesis cannot be recognized until a hem- 
orrhage has taken place, and the subjects are usually healthy- 
looking, characteristically supposed to have blonde or reddish 
hair, blue eyes, and a fair, transparent skin. There is a strong 
tendency to joint-affections of a painful type, which may 
resemble rheumatism of the larger joints closely. When a 
single large joint is involved in a child it is frequently mistaken 



DISEASES OF THE BLOOD 301 

for a tuberculous lesion. A hemorrhage may be preceded by 
an attack of arthritis or circulatory disturbances, such as oppres- 
sion, palpitation, and rush of blood to the head. 

The prognosis is always grave, one half of the cases dying 
before the seventh year. As there is a tendency to outgrow 
the condition, the prognosis becomes more favorable with ad- 
vancing years. There seems to be no unfavorable effect upon 
the functions of menstruation and parturition in female 
bleeders. 

Treatment. — Powers (Surgical Diseases of Children) ad- 
vises against the use of styptics in hemophilia, as they are 
always useless. The application of fresh blood to the wound 
has acted successfully (Bieudwald). The inhalation of carbonic 
acid gas (Wright, British Med., Jour., 1894) has a decided 
influence over the epistaxis, which may also require plugging 
of the nares. Supra-renal extract is a most powerful styptic 
and less objectionable than tannin or perchloride of iron. Gel- 
atin is highly recommended by some surgeons but is not reliable. 
The local use of cephalin (McLean) has proven most useful. 
Fresh human serum may be given intravenously at the same 
time. 

As a constitutional remedy phosphorous corresponds most 

closely to the condition. The lime salts, given over a long period 

of time, may prove helpful in improving the bleeding tendency. 

PURPURA. 

The term purpura includes a variety of affections character- 
ized by the development of reddish macules of varying size upon 
the skin due to spontaneous hemorrhage. 

It may occur symptomutically after the administration of 
certain drugs (iodides, quinine, potassium chlorate, etc.) ; 
in the course of certain of the infectious diseases, notably in 
septicemia, cerebro-spinal meningitis, small-pox, septic endo- 
carditis, and sometimes in measles ; and as a result of cachexia, 
mechanical and nervous disturbances. Primarily it is observed 



302 DISEASES OF CHILDREN 

in the following clinical forms: Purpura simplex, purpura 
rheumatica, Henoch's purpura, and purpura hemorrhagica. 
Before classifying a case as one of purpura it is important to 
exclude any of the above mentioned conditions in which the skin 
hemorrhages are but a secondary manifestation and also elimi- 
nate such diseases as hemophilia and acute lymphatic leukemia. 

Purpura simplex is characterized by the appearance of crops 
of purpuric spots, mainly upon the legs, which may be accom- 
panied by slight fever, articular pains and diarrhea. The spots 
are bright red in color, do not disappear upon pressure, and 
gradually fade to a purplish and later to a greenish or dirty- 
yellow shade, the course pursued by all purpuric lesions. The 
duration is about one week. A rheumatic history is often 
present. 

Purpura rheumatica, or peliosis rheumatica (Schonlein), 
as the name implies, bears a strong relationship to rheu- 
matism. The purpuric rash develops in conjunction with 
multiple arthritis. The onset is usually that of an atypical 
rheumatic fever: lassitude, fever, sore throat, articular pains, 
and in the course of a few days the rash appears, which may be 
associated with urticaria. It is more common in adults than 
in children. 

Henoch's purpura is, according to Henoch's own descrip- 
tion, a complicated clinical picture, in which vomiting, intes- 
tinal hemorrhage and colic are associated with the symptoms of 
purpura rheumatica (Yorlesungen u. Kinderkrankh.) . The 
prognosis of this variety is usually favorable, Henoch reporting 
six cases, with recovery in all, and Osier eleven cases, with three 
deaths (Amer. Jour, of Med. Sciences, Dec, 1895). The 
diagnosis is often beset with difficulty, especially when there are 
no external hemorrhages. The symptoms may be entirely 
abdominal and simulate appendicitis so closely that cases have 
frequently been operated upon for appendicitis. Blood in the 
stools will usually be found on investigation and an acute 
hemorrhagic nephritis is a frequent accompaniment of the pur- 



DISEASES OF THE BEOOD 303 

puric condition. In typical cases the paroxysms of abdominal 
pain and bloody stools show a tendency to recur and joint 
manifestations may develop during the remissions. 

Purpura hemorrhagica {morbus maculosus Werlhofii). — 
Purpura hemorrhagica is characterized by the development of 
extensive subcutaneous hemorrhages, bleeding from the mucous 
membranes and a pronounced secondary anemia. The blood 
shows a marked reduction in the platelets, which accounts for 
the spontaneous hemorrhages. 

The spots may extend over the entire body, their size varying 
from that of a pin-head to fairly large blotches. The macules 
are often interspersed with vesicles, produced by circumscribed 
hemorrhages into the rete Malpighii. The cutaneous hemor- 
rhages are followed by bleeding from the mucous membranes 
and internal organs, particularly from the kidneys. Hematem- 
esis is also noted in some cases. The duration is from ten days 
to two weeks in favorable cases. Death may result from exhaus- 
tion, or from a cerebral hemorrhage. 

Purpura fulminans is a variety of purpura hemorrhagica 
occasionally seen in children. It is characterized by rapidly- 
developing cutaneous hemorrhages, which may of themselves be 
the cause of death. If the patient survives gangrene and slough- 
ing may occur in the affected parts. 

Treatment. — In cases of simple purpura and in the rheu- 
matic forms, the best results will be obtained by prescribing 
for the underlying constitutional condition. Such remedies as 
bryonia, arnica, hamamelis and rhus tox. cover the symptoms 
found in these cases. 

In the hemorrhagic form china, crotalus, lachesis, Icali 
hydro jodicum, phosphorus, rhus venenata, secale and sul- 
phuric acid should be studied and differentiated. 



CHAPTER XIV. 

DISEASES OF THE NERVOUS SYSTEM. 

The nervous system in infancy presents certain anatomical 
and physiological characteristics which are responsible for some 
of the peculiarities noted in the neurological conditions encoun- 
tered at this time of life. The psychology of the child must 
also be taken into consideration in order to properly interpret 
some of the symptoms and nervous disturbances of childhood. 

The brain of the newborn represents one quarter of the body 
weight; nevertheless, it is in an immature condition both ana- 
tomically and physiologically. Owing to its large size and great 
vascularity, and because the cranium is only a membranous 
covering at this time of life, it is very liable to injury during 
parturition. The most important feature of the infantile brain 
is the imperfect development of the higher inhibitory centres 
and the absence of myelin sheaths for the neurons comprising 
the pyramidal tracts. This explains the tendency to convulsions 
(eclampsia) observed in infancy and the heightened reflexes 
normally present at this time of life. 

In young infants there is a physiological hypertonia of the 
muscles and the tendon reflexes are therefore exaggerated. The 
extremities also offer a certain degree of resistance to passive 
motion and it may at times be difficult to determine whether or 
not a spastic condition is present. The knee-jerk is most sat- 
isfactorily obtained when the infant is preoccupied in nursing 
or when its attention is attracted by some object of interest. 
The examiner should place the left hand under the knee, raise 
the same sufficiently to flex the leg on the thigh and then strike 
the patella tendon with the middle finger of the right hand. 
In older children it is sometimes more satisfactory to have the 
child sitting up with the legs hanging over the edge of the bed 
or chair. 



DISEASES OF THE NERVOUS SYSTEM 305 

The knee-jerk is exaggerated in lesions affecting the upper 
neurons, i.e., cerebral lesions. In lesions of the lower neurons, 
i.e., spinal cord and spinal nerves, it is diminished or abolished 
(poliomyelitis, diphtheritic paralysis). 

Kernig's sign is found in meningitis (about 85 per cent of 
cases), and at times in cerebellar hemorrhage and in lesions 
at the base of the brain. It is a phenomenon of hypertonia of 
the flexor muscles of the legs. This condition was originally 
described as an inability to extend the leg upon the thigh when 
in the sitting posture, owing to tonic spasm of the hamstring 
muscles. When the dorsal decubitus is assumed, the leg can be 
straightened out, but if the thigh is now flexed upon the abdo- 
men it again becomes impossible to straighten out the leg and 
a spasmodic resistance is noted in the contracted muscles. 
Babinski's sign is an alteration in the type of response of the 
plantar reflex, there being hyperextension of the great toe in- 
stead of flexion. It indicates a disturbance in the pyramidal 
tracts. This most valuable diagnostic sign in older children 
and adults is of no clinical value during infancy since the nor- 
mal infant gives a plantar reflex quite similar to Babinski's sign. 
The explanation for this is most likely the lack of development 
of the myelin sheaths for the fibres of the pyramidal tract. 
After the infant has learned to walk the normal plantar reflex 
usually develops. 

An important clinical fact to bear in mind is that the major- 
ity of brain lesions during infancy and early childhood are 
either cortical or basilar. Hemorrhage into the internal cap- 
sule is rare, the usual type of hemorrhage being pial in character. 

The function of the cranial nerves is determined in the 
manner employed for adults, as far as that can be carried out. 
Strabismus is normally present in infants under three months. 
After that age the infant acquires ocular control and begins to 
use its eyes in a coordinated manner. 

Motor 'paralysis is detected by observing whether or not the 
child is able to move its extremities. Inability to walk may be 
21 



306 DISEASES OF CHILDREN 

due either to paralysis or to rickets (rachitic pseudo-paralysis). 
In the latter condition the child can move the legs, as tickling 
the sole of the foot will prove, but it is unable to stand or to walk. 
Spasticity, or "lead-pipe rigidity," is found in cerebral palsies, 
usually in association with impaired mentality. 

The mental development is difficult to gauge in infancy. 
The early signs of amentia, or idiocy, are inability to support 
the head (normal at four months) ; amaurosis (amaurotic 
family idiocy) ; crying without cause, backwardness in grasping 
and holding objjects ; inability to nurse properly. Normally, a 
child should begin to walk after it is a year old and shortly 
after this time it should commence to repeat words and use 
them intelligently. According to West, a backward child would 
be normal were it of a younger age, while an idiot is abnormal 
for any age. 

Reaction of degeneration. — By the "reaction of degeneration" 
is meant the electrical phenomena which take place in a muscle 
supplied with a motor nerve whose spinal ganglion cell has been 
destroyed, or, in fact, whose lower neuron has been affected at 
any point in its course. The reaction is distinctive and differs 
so markedly from the reaction obtained by the galvanic current 
in a normal muscle that it is a reliable diagnostic sign. 

Briefly stated, the muscle loses its irritability to the faradic 

current, while the contraction with the galvanic current becomes 

slow and tetanoid in character, the main change, however, being 

that it first responds to the anodal closure with a gradually 

increasing current instead of to the cathode, as occurs normally. 

The reaction of degeneration is found typically in poliomyelitis 

anterior. It also occurs in progressive muscular atrophy and in 

multiple neuritis. 

PSYCHOSES. 

Night terrors and morbid fears are mental disturbances in 
which hallucinations of various kinds are developed in the 
child's imagination through fright, or through the suggestions 
resulting from the recital of ghost-stories and fairy-tales, or 



DISEASES OF THE NERVOUS SYSTEM 307 

from vicious threats. The rational explanation for a large 
number of cases of frightened awaking from sleep is, in mj 
belief, a choking spell resulting from enlarged tonsils and 
adenoids or some other form of suffocative attack (nightmare). 
As many children with adenoids present these symptoms the 
throat should always be examined in such cases. Another 
common cause of disorders of sleep is gastro-intestinal irritation ; 
but in these cases the symptoms are reflex in character, and do 
not approach the nature of a psychosis, as do the above. In 
neurasthenia and lithemia similar disturbances are observed. 
The idiopathic fears and terrors point to a highly neurotic 
form of constitution, and they may indeed be the forerunners 
of a more serious mental trouble. It should also be remembered 
that in epilepsy there may be a psychic equivalent for the 
convulsion and that a child with unusual mental symptoms may 
be an epileptic. 

IDIOCY AND MENTAL DEFICIENCY. 

Idiocy is mental deficiency in the extreme form. The idiot is 
a helpless, hopelessly stupid child who cannot care for himself 
and who cannot be taught to do anything intelligently. He may 
attain the mentality of an infant one or two years old but as a 
rule he does not show as good intelligence as a normal infant 
and he may be exceedingly abnormal in disposition and in his 
actions. 

Mental deficiency is encountered in different degrees and a 
child may appear to be normal until a psychological examination 
has been made and shown it to be mentally backward. An 
individual whose mental development has been arrested at a 
stage corresponding to the mentality of a normal child of 
ten or twelve years is spoken of as a moron. Two types of 
idiocy are recognized, namely primary amentia, which is a 
mental defect due to an intrinsic cause (morbid heredity), and 
secondary amentia, due to extrinsic causes such as traumatism, 
infection or unfavorable environment. 



308 DISEASES OF CHILDREN 

In the etiology of idiocy hereditary transmission plays the 
most important role; of all mental derangements it is the one 
most frequently transmitted directly. A neuropathic family 
history; parental epilepsy or insanity; consanguine mar- 
riages; alcoholism in the parents; worriment or fright of the 
mother during pregnancy, are etiological factors of less import- 
ance. The pathological lesions responsible for idiocy are either 
present at the time of birth, having developed in utero, as in 
primary amentia, or they may develop after birth as in the case 
of traumatic, inflammatory, epileptic and paralytic idiocy. 

The following classes of idiocy are recognized by Ireland: 

Genetous idiocy, cases which cannot be traced to any known 
specific disease, and whose pathology cannot be properly diag- 
nosed until after death. The condition of mental deficiency is 
present before birth. There is usually a history of imbecility 
in one of the parents or in the family of one of the parents. 
Goddard has shown that feeble-mindedness is hereditary and 
is transmitted according to the Mendelian law, like any other 
character. It is a Mendelian recessive character. 

The expression of the idiot is generally good-natured but 
stupid ; the head is not necessarily small, although irregular in 
shape. Stigmata of degeneration are usually present. The 
early symptoms of genetous idiocy are constant sleeping in 
early infancy and absence of interest and attention to its sur- 
roundings, inability of the infant to suckle well, a feeble grasp, 
failure to react to sensory impressions and sight, and backward- 
ness in walking and talking. The occurrence of such symptoms 
in the presence of a neuropathic heredity should always arouse 
our suspicions. 

Amaurotic family idiocy is a clinical type described by Sachs. 
It occurs in Jewish families, the child being apparently normal 
at birth but gradually sinking into a state of complete idiocy 
with loss of sight. The outcome is fatal. 

Microcephalic and hydrocephalic idiocy are forms of idiocy 
which are usually congenital, like genetous idiocy, although 
hydrocephalus may not develop until after birth. 



DISEASES OF THE NERVOUS SYSTEM 309 

Epileptic and paralytic idiocy belong to the acquired forms 
of the disease, developing in consequence of some other disease 
of the nervous system. 

Paralytic idiocy depends upon destruction of cerebral sub- 
stance from lesions which may have developed either before 
birth (congenital idiocy) or after birth (acquired idiocy). In 
these cases there is frequently sufficient asymmetry of the 
brain present to produce noticeable inequality of the skull. 
Hemiplegia, more or less complete, the arm usually more 
affected than the leg, or diplegia are the accompanying condi- 
tions. Frequently the child's mentality is less impaired than 
mere appearances would indicate. The physical handicap 
makes the mental deficiency more apparent than real and much 
can be accomplished in these cases by proper training. 

Inflammatory idiocy includes those cases following meningitis 
or some of the infectious fevers (post-febrile insanity) ; also 
idiocy depending upon atrophy and hypertrophy of the brain, 
the result of inflammatory changes. 

Sclerotic idiocy presents sclerosis with atrophy of the brain, 
diffuse sclerotic changes, and glioma with sclerosis (Wilmarth, 
Alienist and Neurologist, Oct., 1890). As predisposing causes 
are mentioned the tuberculous diathesis, neuropathic heredity; 
alcoholism. Accidents to the mother during pregnancy and 
traumatism to the child's head during or after birth are exciting 
causes. 

Syphilis no doubt is responsible for many cases of idiocy. 
It is perhaps more common to find mental and physical inferior- 
ity and certain neurological conditions resulting from inherited 
syphilis than imbecility. "Our verdict at the present time is 
that, as regards the causation of mental defect, syphilis is a 
sufficient factor in itself, and often has a deciding influence 
when there is a morbid heredity or other unfavorable factors" 
(Shuttleworth and Potts, Mentally Deficient Children). The 
pathological lesions which congenital syphilis may give rise to 
are "a meningitis, a hydrocephalus, an endarteritis, gummata, 



310 DISEASES OF CHILDREN 

juvenile tabes, and juvenile general paralysis of the insane" 
(Batten). 

Traumatic idiocy results from pathological changes in the 
brain, induced by a destructive injury. A certain amount of 
inflammatory action must always be taken into consideration in 
these cases, but the effects of the injury predominate over those 
of the inflammation. The traumatism is usually a birth injury 
(see paralytic idiocy). 

Deaf -mutism is a form of mental deficiency through depriva- 
tion of the sense of hearing. If deafness is acquired after the 
seventh year the child usually escapes mutism. 

Treatment. — Medical treatment is of no value in improving 
the child's mentality excepting perhaps in cases of syphilitic 
origin. The chief factors in the care of the feeble-minded child 
are careful nursing, or "mothering," improving the child's 
physical condition by the use of a constitutional remedy, proper 
diet and the correction of such defects as nasal obstruction 
(adenoids) and errors of vision and finally skilful training. 
During the first six years of life the backward child is still 
practically in its infancy and at this time its physical welfare 
alone need be looked after. Some training, such as the acquisi- 
tion of habits of bodily cleanliness and learning to feed itself 
may be begun. After the sixth year, however, it should be 
placed in the hands of a tutor who has had special training in 
the education of feeble-minded children. The best results are 
usually obtained when the child is sent to a special school 
because it here receives the advantages of class work and also 
the benefit of coming under the care of highly trained specialists 
in this work. 

MONGOLIAN IDIOCY. 

Mongolian idiocy is a form of primary amentia not of 
hereditary origin but occurring as a result of failing procreative 
powers on the part of the parents. Mongols often represent the 
last born child of a large family in which case the mother is 
nearing middle life or has become exhausted from too frequent 



DISEASES OF THE NERVOUS SYSTEM 311 

childbearing. Extreme age of the father may also be noted in 
the history of the case. Shuttleworth and Potts refer to the 
mongol as an unfinished child, representing a phase of fetal 
life. There is no evidence of syphilis as an etiological factor. 
The sexes are about equally affected. 

The mongol presents a characteristic appearance, his resem- 
blance to the mongolian race giving him the name. He is 
undersized and physically frail; many mongolians die during 
infancy and few grow up to adult life. The head is round, or 
brachycephalic; the eyes are obliquely set and almond-shaped 
and an epicanthic fold is present. The nose is flat and the 
tongue is transversally fissured and has hypertrophied papilla?. 
The fissures, however, do not develop until the child is three to 
four years old. The tongue is not enlarged as in cretinism. 
The hands are broad and the fingers are short. The little finger 
often shows an inward curve of the distal phalanx. A congen- 
ital heart lesion is frequently encountered in these children. 
They are usually mouth-breathers but the removal of adenoids 
does not bring much relief from this condition since it is mainly 
due to the poorly developed nasal chambers and high arched 
palate and to lack of attention on the part of the child. 

The mental and physical development is slow and never 
reaches beyond the mentality of a very young child. They do 
not walk until after the second year and are late in learning to 
talk. Their speech is always very elementary and usually 
difficult to understand. They may show great love for music, 
however, and they often show unusual powers of mimicry but 
they seldom can be taught to do more than the simplest things 
in life. Milder types, simply suggestive of the mongol, may 
prove more satisfactory from the mental standpoint. 

Mongolism is frequently mistaken for cretinism and it is 
most important, both from the standpoint of prognosis and 
treatment, that the two conditions be not confused. In mongol- 
ism the child's abnormality exists from birth while cretinism 
does not show its characteristics until after the sixth month. 



312 DISEASES OF CHILDREN 

The slanting, close-set eyes; epicanthus; rounded, brachy- 
cephalic head give the mongol a very characteristic appearance, 
quite different from the short, stunted, fat, pot-bellied cretin 
with his dull, apathetic face, large head, eyes far apart, thick 
lips and protruding tongue. 

Treatment. — Mongolism differs from cretinism in that it 
does not respond to treatment with thyroid gland extract. Small 
doses of thyroid extract no doubt benefit some cases purely 
through the tonic effect of this substance on metabolism but the 
large doses which are frequently used do more harm than good. 
Careful nursing and training as recommended in the manage- 
ment of feeble-minded children applies to the mongol in every 
particular. 

SPORADIC CRETINISM. 

The clinical type of congenital hypothyroidism in which the 
podiatrist is particularly interested is known as sporadic cre- 
tinism because it occurs sporadically in our midst and bears a 
close clinical resemblance to the endemic form of cretinism 
which has been observed for years in certain mountainous re- 
gions of Europe The pathology of cretinism is atrophy or 
absence of the thyroid gland. The results are dwarfing of both 
the physique and mentality of the individual together with signs 
of myxedema. 

As a rule the infant is normal at birth since it receives 
sufficient thyroid secretion for its normal development from 
the maternal blood. After the sixth month, however, it begins 
to give indications of mental dulness and retarded development. 
The earliest symptoms are apathy, obstinate constipation with 
a large abdomen; the skin becomes harsh and dry. The fully 
developed cretin is very characteristic. He presents a dwarfed 
body, short legs and arms, sluggish mentality or idiocy, a large 
square head with eyes set wide apart, pug nose and pouting lips. 
The tongue becomes enlarged from myxedematous infiltration 
and the skin is loose and redundant from the same cause. The 



DISEASES OF THE NERVOUS SYSTEM 313 

abdomen is large and pendulous and there is usually an umbili- 
cal hernia. 

The remarkable fact in connection with cretinism is the 
striking result which follows the administration of thyroid gland 
in these cases. There is a prompt improvement in the child's 
mental and general condition. It becomes bright, constipation 
disappears and it begins to grow and lose its unsightly features. 
Treatment, however, must be continued indefinitely or the child 
will sink back into its abnormal state. The earlier treatment 
is begun the better the outlook for mental advancement. The 
best results to be expected are that the child will be approxi- 
mately normal; they usually remain backward to some extent 
although capable of acquiring a certain amount of knowledge. 
Two to three grains daily of the thyroid gland extract is usually 
necessary to keep the child in its best condition. 



MENINGITIS. 

Meningitis, or inflammation of the meninges of the brain, is 
usually encountered in the acute form during childhood and 
may be either primary or secondary. The chief forms of pri- 
mary meningitis are acute (epidemic) cerebrospinal meningitis 
and tuberculous meningitis. The epidemic form of cerebro- 
spinal meningitis is due to infection with the meningococcus 
intracellularis ; it occurs sporadically as well as in epidemics but 
infection is spread by "carriers" and it is usually encountered 
during the winter months. 

Secondary meningitis is a complication of one of the acute 
infectious diseases and it may, therefore, develop during the 
course of pneumonia, enteritis, influenza, typhoid fever and 
purulent otitis media. It usually runs the course of a purulent 
meningitis. 

Serous meningitis, or meningismus, is an acute inflamma- 
tion of the pia mater with resulting serous exudate. It is usually 
a secondary condition, developing in conjunction with some 



314 DISEASES OF CHILDREN 

acute disease, notably a gastrointestinal affection as a secondary 
infection of the meninges with germs of low virulence or it is 
purely toxic in origin. The symptoms are similar to those 
observed in other forms of meningitis although less pronounced. 
There may be convulsions and strabismus; infants present 
bulging fontanels while older children complain of headache. 
Stupor gradually develops and such symptoms as rigidity of the 
neck and Kernig's sign may be present. 

Diagnosis. — The diagnosis of meningismus is based upon the 
presence of symptoms of brain irritation and pressure which 
accompany some acute infectious process, such as, infectious 
diarrhea, pneumonia or otitis media and which tend to clear 
up with recovery from the primary disease. Lumbar puncture 
is of the greatest help in the diagnosis. An increase in the 
amount of cerebrospinal fluid is found but the fluid is clear 
and there is no increase in its cellular elements or in its 
globulin content. Cultures made from the fluid are negative. 

Treatment. — The treatment is chiefly that of the underlying 
condition. Lumbar puncture gives prompt relief, as a rule, 
from the cerebral symptoms. It is not uncommon to see the 
child come out of its stupor and to note a cessation of convulsions 
after the intracranial pressure has been relieved by a successful 
puncture. 

When the cerebral symptoms dominate the clinical picture 
such remedies as apis, belladonna, cicuta, helleborus, cuprum 
arsenicosum and hyoscyamus suggest themselves and may be 
prescribed on their characteristic symptoms as given elsewhere. 
Whenever there is any doubt as to the diagnosis, particularly 
early in the case and during an epidemic of cerebrospinal 
meningitis the safest mode of procedure is to give an intraspinal 
injection of meningococcus serum. ~No harm can arise from this 
procedure and should the case later prove to be one of meningitis, 
valuable time in treating the case has been gained. 



DISEASES OF THE NERVOUS SYSTEM 315 

EPIDEMIC CEREBROSPINAL MENINGITIS; SPOTTED FEVER. 

Epidemic cerebrospinal meningitis is caused by the meningo- 
coccus intracellularis which was discovered by Weichselbaum 
in 1888. It is a Gram negative diploeoccus, found within the 
polynuclear cells of the spinal fluid. Infection takes place by 
way of the upper respiratory tract where the meningococcus is 
harbored and thence carried to the meninges by way of the blood 
current. The organism can be recovered from the nose and 
throat of infected individuals and from "carriers" of the disease. 

Epidemics occur most frequently in the winter months. It 
does not spread rapidly and an epidemic may therefore extend 
over many months. Sporadic cases can probably be explained 
on the ground of contact with a carrier who has brought the 
infection from some distance. Young children appear to pre- 
sent a special susceptibility to the disease. Poverty, overcrowd- 
ing and unhygienic surroundings are predisposing causes. 

Pathology. — Rapidly fatal cases may show only the signs of 
severe cerebral congestion. A fully developed case, however, 
presents a typical purulent meningitis. Cases which have 
run a protracted course show thickening of the meninges; 
degenerative changes in the cerebral cortex; marked distention 
of the ventricles. 

The pathological process is an exudative inflammation of the 
pia mater affecting chiefly the base of the brain and the posterior 
surface of the cord. The exudation into the cord is most 
pronounced in the dorsal and lumbar region. Effusion into 
the ventricles and into the pia mater of the cortex co-exists to 
a lesser degree. The cranial nerves are more or less involved 
according to the amount of exudate and pressure which is 
present. The auditory nerve is especially liable to involvement 
and permanent nerve deafness is a common after effect of the 
disease. The exudate is at first sero-fibrinous, soon becoming 
purulent. It is rich in polynuclear leucocytes. Some degree 
of cerebritis may co-exist. 



316 DISEASES OF CHILDREN" 

Associated lesions that may be encountered are cutaneous 
hemorrhages (petechia?); nephritis; bronchopneumonia; paren- 
chymatous degeneration of the heart, liver and kidneys; 
arthritis. 

Symptoms. — The disease is very irregular in its clinical 
manifestations and may either prove fatal within a few hours 
or run a long and protracted course. There are intermediate 
cases of moderate severity in which perfect recovery takes place. 
Epidemic cerebrospinal meningitis is the least fatal form of 
meningitis, but unfortunately many cases that recover are left 
with some permanent disability such as deafness, blindness, 
idiocy, paralysis. 

A number of types of cerebrospinal meningitis are to be 
recognized, the classification being based chiefly upon the 
duration and severity of the symptoms. The invasion, however, 
shows a general resemblance in all cases. The onset is sudden, 
with either vomiting or convulsions, intense headache and fever, 
and soon the most characteristic symptom of the disease, 
namely, rigidity of the neck muscles and retraction of the head, 
makes its appearance. 

In the fulminating form the onset is so sudden and over- 
whelming that the patient may succumb within a few hours. 

These foudroyant cases usually prove fatal in the first few 
days. Deep coma develops early and is associated with retrac- 
tion of the head and even opisthotonos. Strumpell refers to 
a class of cases with sudden and severe onset, similar to the 
fulminating form, which, however, abort in the course of 
several days and go on to complete recovery (abortive form). 
There are also mild cases, in which the entire clinical course 
is marked by slight development of the symptoms. A child thus 
affected may show the meningoccoccus in its cerebrospinal fluid 
and yet not appear to be seriously ill. 

Protracted cases are not uncommon. The symptoms may 
extend over a period of from two to three months and the child 
ultimately recover. In these protracted cases the fever dis- 



DISEASES OF THE NERVOUS SYSTEM 317 

appears for several days and then recurs. Such cases have been 
designated "intermittent cerebrospinal fever" (von Ziemssen). 
A pronounced degree of emaciation develops in the case of this 
type. There is a protracted form of cerebrospinal meningitis 
which has been described in the literature as ''posterior basic 
meningitis" thus giving the impression that it is a distinct 
disease. Posterior basic meningitis, or chronic basilar menin- 
gitis is, however, identical with cerebrospinal meningitis both 
in etiology and pathology. It is usually encountered in infants 
because the anatomical pecularities of the brain at this time of 
life predispose to the exaggerated basilar manifestations. 

Typical cases present the following symptoms: 

The onset is sudden although such prodromal symptoms as 
headache, malaise, conjunctivitis and slight fever may be noted. 

The initial symptoms point to the brain as the seat of the 
affection. There are vomiting or convulsions, sometimes a chill ; 
intense occipital headache and high fever. To these symptoms 
stiffness of the neck is soon added and with the outpouring of 
exudate more or less disturbance of consciousness. 

In infants bulging of the fontanel is to be noted. Delirium 
is a common symptom with older children. Complete stupor 
develops, although often the patient may be aroused, or lucid 
moments will alternate with the stupor. Fever and delirium 
may be present only at night, the child being rational during the 
day and able to sit up in bed and play with its toys (Koplik). 

The headache may be so intense that we will observe the child 
knitting its brows and moaning with pain, while at the same 
time it is so deeply in stupor that we can neither arouse it nor 
get a response. Beside the cerebral manifestations we will 
observe marked hyperesthesia of the cutaneous surface, due to 
the irritation of the posterior nerve roots (spinal) by the inflam- 
matory exudate. This hyperesthesia is most marked in the 
lower extremities. 

Retraction of the head occurs earlier (within a day or two 
or even within a few hours) and is more pronounced and more 



318 DISEASES OF CHILDREN 

persisting in cerebrospinal fever than in any other form of 
meningitis (Heubner). As a rule, there is tenderness along the 
entire spine, which may be rigid or arched. 

Disturbances in the functions of the cranial nerves are mani- 
fested as hyperesthesia of the sensory and irritation of the motor 
nerves. Thus photophobia, tinnitus aurium and disturbances 
of smell are encountered. Optic neuritis may develop with 
consequent blindness, and permanent deafness is one of the 
unfortunate sequelae of the disease. 

Spastic strabismus; irregular but reacting pupils; ptosis; 
spasm of the facial muscles and dysphagia are all to be observed. 
In contradistinction to tuberculous meningitis, there is more 
tendency to irritation and less to actual paralysis in cerebro- 
spinal meningitis than in the former. 

The extremities are rigid, the arms usually being flexed while 
the legs are straightened and resist passive movements. If, 
however, we flex the thigh upon the abdomen, or if the patient 
attempts to get up, spasmodic flexion of the leg upon the thigh 
takes place. This phenomenon is known as Kernig's sign. 
It is readily demonstrated by flexing the thigh upon the abdo- 
men with the patient in the dorsal position, and then attempting 
to extend the leg on a line with the thigh. Kernig's sign 
is present in a large proportion of all cases of meningitis, but 
especially when the meninges of the cord are at the same time 
involved. It indicates irritation of the pyramidal tracts; 
Fraenkel (New York) thinks the phenomenon depends upon 
traction on the cauda equina?, and he calls attention to the fact 
that we often can see the Babinski sign take place in the foot 
simultaneously with the occurrence of the Kernig. 

The cutaneous manifestations are important, and we should 
not forget that the disease acquired its old name from the 
petechial rash that is present in about a third of the cases. 
In Osier's cases the rash was common. Fully one-half, if not 
more, present herpes labialis or facialis (Strumpell). 

The fever is irregular and does not conform to any type of 



DISEASES OF THE NERVOUS SYSTEM 319 

temperature curve. The temperature is usually high in the 
beginning and there may be hyperpyrexia in the more severe 
cases. It is usually irregular and marked by remissions and even 
intermissions of several days at a time. 

The pulse is rapid and the characteristic slowing observed in 
tuberculous meningitis is not encountered. In fulminating 
cases, however, it may be slow and irregular. This is a grave 
symptom. The respirations show nothing pathognomonic; 
exceptionally Cheyne-Stokes respiration occurs. 

The blood shows a distinct leucocytosis. 

The duration of the disease is usually from two to three weeks 
although complications may prolong the course while some cases 
tend to become protracted. The early use of Flexner's anti- 
meningococcus serum tends to materially shorten the course of 
the disease as well as to decidedly reduce the mortality. 

Complications are observed in some cases, they are more 
common in some epidemics than in others. Aside from the 
complications on the part of the nervous system already referred 
to there may be clonic contractions and paralysis of individual 
extremities and occasionally unilateral paralysis. They appear 
to be due to various pressure conditions by meningeal exudates 
or possibly they owe their origin to variations in circulatory 
conditions, but at the autopsy a clear insight as to what has 
caused these paralyses is by no means always obtained 
(Eichhorst). 

Pneumonia and arthritis may occur as metastatic inflamma- 
tions. The arthritis of cerebrospinal meningitis closely re- 
sembles acute articular rheumatism and may be associated 
with endocarditis. 

As sequelae, long-continuing nervous disturbances, such as 
vertigo; headache; loss of memory; neurasthenia are common. 
Permanent deafness, blindness, epilepsy, idiocy and chronic 
hydrocephalus may also be observed. 

Prognosis. — Excepting in the mild and abortive cases the 
prognosis is grave, unless prompt serum treatment is instituted. 



320 DISEASES OF CHILDREN 

Before the time of Flexner's serum the mortality was about 60 
per cent. Now it is about 25 per cent in cases treated 
with serum. 

Diagnosis. — In fulminating cases that die before the clinical 
picture of the disease is developed, it is naturally impossible 
to make a diagnosis. When, during an epidemic, however, a 
child develops fever, vomiting or convulsions and rapidly goes 
into a state of coma, it is fair to surmise that we are confronted 
with a case of cerebrospinal meningitis. Should retraction of 
the head develop, the diagnosis is almost certain. We must, 
however, not forget that pneumonia may begin precipitately 
with marked cerebral symptoms. Careful exploration of the 
chest will decide the question under these circumstances. When 
pneumonia complicates cerebrospinal meningitis the pulmonary 
symptoms do not develop until later in the disease. 

Osier has called attention to cases of typhoid fever beginning 
abruptly with delirium, headache, retraction of the head and 
high fever. If such a case dies early, differentiation is impos- 
sible unless fluid containing the meningococcus can be obtained 
from the spinal canal. 

Differential diagnosis is mainly between cerebrospinal and 
tuberculous meningitis. In cerebrospinal meningitis the onset 
is more sudden; the fever is higher; retraction of the head 
occurs earlier and is more marked and the nervous manifesta- 
tions are more irritative and less inclined to become paralytic 
in nature. The hyperesthesia of the skin and the petechial rash 
when present are strong, confirmatory symptoms. Then again, 
the presence of an epidemic is to be taken into consideration 
and in the case of tuberculous meningitis a tuberculous history 
may be obtained. 

The examination of the spinal fluid obtained by means of a 
lumbar puncture, offers the most positive data for confirming 
the diagnosis. The fluid is increased in both diseases but not 
so markedly in cerebrospinal meningitis as in tuberculous men- 
ingitis. It is turbid and of a milky appearance while in tuber- 



DISEASES OF THE NERVOUS SYSTEM 321 

culous meningitis it is perfectly clear. Globulin is increased 
in both diseases and the reduction of Fehling's copper solution 
is diminished. In poliomyelitis the reduction of the copper 
solution is positive. The sediment consists of polynuclear leu- 
cocytes in great abundance and the Gram-negative intracellular 
diplococcus of Weichselbaum can usually be demonstrated. 

Treatment. — The best results in the treatment of cerebro- 
spinal meningitis are obtained by the use of Flexner's anti- 
meningitis serum. This is a polyvalent serum prepared by 
immunizing horses with the toxins and cultures of a variety of 
strains of meningococci. A recent refinement in the serum 
treatment of cerebrospinal meningitis is to culture the organ- 
isms found in the patient's cerebrospinal fluid and test out a 
number of sera against the culture in order to determine the 
one most suitable for the case. While this is an excellent mode 
of procedure to adopt in hospital work, still it offers difficulties 
for private practice where we must depend on a Board of 
Health serum or one of the commercial sera of good repute. As 
in the case of diphtheria, the earlier the serum is employed the 
better will be the results ; therefore it is always wise to be pre- 
pared to give an intraspinal injection of serum at once, if the 
appearance of the cerebrospinal fluid corroborates the clinical 
diagnosis. If the further laboratory examination of the fluid 
verifies the diagnosis a second injection of serum may be given 
the next day and the injections repeated until the clinical symp- 
toms have been controlled. The dose for an infant is 10 to 
15 c. c. and for a child 20 to 30 c. c. 

As an adjuvant in the treatment hot baths are of a decided 
value. They are indicated in the beginning of the disease and 
undoubtedly exert a sedative effect upon the nervous manifesta- 
tions. Beginning with a temperature of 98° F. the heat can be 
increased daily by a degree, up to 105° F. One bath daily is 
sufficient, and as little handling of the patient as possible is to 
be advised on account of the suffering caused thereby. An ice- 
22 



322 DISEASES OF CHILDREN 

bag to the head sometimes gives relief from the intense head- 
ache. 

Of the greatest importance is the feeding of these cases. Ex- 
treme emaciation results unless we take advantage of every 
opportunity of getting sufficient nourishment into the child. 
Tube feeding may prove necessary in extreme cases. 

Remedies. — In the early stages belladonna is the most 
valuable remedy, corresponding to the meningeal congestion 
both symptomatically and pathologically. Bryonia, apis melli- 
fica and cicuta virosa are indicated when the signs of meningitis 
are more fully established. When toxic symptoms predominate 
over inflammatory, such remedies as hyoscyamus, opium and 
helleborus are more suitable. Cases with marked petechial 
eruption and of protracted character call for arsenicum, the 
snake venoms, and especially rhus toxicodendron. Cases with 
convulsions call for cicuta virosa. 

Actea racemosa is useful for the pains and spasm persisting 
after the acute symptoms have subsided (Searle). There is 
intense occipital headache, like a bolt being driven from the 
nape of the neck to the vertex, felt with every pulse-beat ; stiff- 
ness of neck; delirium. 

Apis mellifica. — Sopor, interrupted by piercing shrieks; 
squinting; pupils dilated; retraction of head (stage of effusion). 

Arsenicum. — Protracted and adynamic cases, intermittent 
type. 

Belladonna. — High fever; convulsions; flushed face; photo- 
phobia; difficulty in swallowing; intense throbbing headache; 
delirium; vomiting; marked drowsiness. 

Bryonia. — Bursting headache ; apathy ; child cries when it is 
touched or moved ; arthritis or pneumonia. 

Cicuta. — The toxicologic reports of this remedy show its pro- 
nounced action upon the meninges of the brain and cord, in 
which it sets up intense congestion with resulting convulsions. 
Various forms of paralysis may follow upon the convulsions. 
More or less disturbance of consciousness is associated. Dr. 



DISEASES OF THE NERVOUS SYSTEM 323 

Baker (Trans. New York Horn. Soc.j 1872) reported most 
promising results from cicuta after using it in an epidemic 
at Batavia, New York. 

Cuprum aceticum has long been recognized as a potent rem- 
edy in meningitis, and was used with success by Dr. George 
Schmidt, of Vienna, for the cerebral symptoms accompanying 
the infectious diseases. Goodno considers cuprum aceticum 
the most generally useful remedy in cerebrospinal meningitis, 
giving it the preference over cicuta when cerebral symptoms 
predominate over the convulsive symptoms. 

Gelsemium. — Early stages, chilliness, aching and prostra- 
tion, photophobia, ptosis and squinting; occipital headache, 
with muscular soreness in the neck ; remitting fever. 

Helleborus. — Stupefaction, child bores its head into the pil- 
low; suppression of urine, convulsions (serous effusion). 

Hyoscyamus. — Muttering or wild delirium, unconsciousness, 
convulsions, pupils dilated, purplish rash. The temperature 
is not as high as in belladonna. 

Kali hydrojod. — Iodide of potash is the remedy chiefly relied 
upon by the old school. There are some encouraging reports 
from its use, and it may be tried with advantage in cases not 
presenting marked symptoms for another remedy. 

Opium. — Deep coma, pupils fixed, stertorous breathing, pulse 
irregular, inclined to be slow, clammy skin. 

Rhus toxicodendron. — Petechial form, patient restless, pro- 
foundly prostrated; herpetic and purpuric eruptions, intense 
aching pains in back and extremities, tongue dry and brown 
with reddish tip. 

TUBERCULOUS MENINGITIS 

Tuberculous meningitis is the commonest form of meningitis 
encountered during infancy. It results from a general tubercu- 
lar infection in which miliary tubercles develop in the meninges 
of the brain. In the majority of instances there is a primary 
focus in the lungs or bronchial glands whence tubercle bacilli 



324 DISEASES OF CHILDREN 

gain entrance into the blood stream and give rise to an acute 
tubercular process in the brain. It is rarely a primary condi- 
tion although in many cases the primary focus in some other 
part of the body is difficult to demonstrate (lungs, bronchial 
glands, mesenteric glands, cervical glands). At times the men- 
ingeal involvement is only part of a general acute miliary tu- 
berculous. Tuberculous meningitis is indicative of a low degree 
of resistance to tubercular infection as the age incidence indi- 
cates. It is perhaps always associated with a recent infection 
with tuberculosis since patients suffering with chronic tubercu- 
losis rarely develop tuberculous meningitis. 

The majority of cases occur from the second to the seventh 
year, although it may be encountered during the first year of 
life. The child may show previous signs of a tubercular infec- 
tion or the disease may develop in an apparently healthy, ro- 
bust infant. Measles and whooping-cough may act as predis- 
posing causes, especially in children suffering with tubercu- 
lous adenitis (cervical or bronchial). It is not uncommon to 
see it develop in successive children in the same family. 

Pathology. — The clinical manifestations of tuberculous 
meningitis result from the marked serous exudate which devel- 
ops in conjunction with the meningitis ("acute internal hydro- 
cephalus") and the deposit of tubercles and fibrinous exudate 
at the base of the brain ("acute basilar meningitis"). 

The pathological changes found in the brain are miliary 
tubercles situated along the course of the blood-vessels at the 
base of the brain, chiefly following the sylvian artery; inflam- 
matory reaction in the pia mater with lymphocytic infiltration ; 
exudation into the ventricles, and more or less infiltration of 
the brain substance (meningoencephalitis). The blood-vessels 
are injected and bathed in a serogelatinous exudate. As a result 
of the intra-ventricular pressure the convolutions may appear 
flattened. Ordinarily the eruption of tubercles is limited to 
the base, but tuberculous deposits may also occur in atypical 
localities producing focal symptoms — cerebral tuberculosis. 



DISEASES OF THE NERVOUS SYSTEM 325 

The clinical manifestations result from the direct pressure of 
the inflammatory products upon the roots of the cranial nerves 
as well as from pressure resulting from the increased weight 
of the brain and the increased intracranial pressure. The sixth 
nerve is especially liable to be affected in this manner while 
the a choked disc" of the optic nerve results from the increased 
intracranial tension. 

Symptoms. — The symptoms of tuberculous meningitis are 
usually divided into three stages in order to describe the typical 
evolution of the clinical course of the disease. Many atypical 
cases, however, are encountered and it is therefore not always 
possible to trace the symptoms in the order given for a classical 
case. The age of the patient must also be taken into consider- 
ation for the characteristic alterations in the rhythm of the 
pulse and respirations, the obstipation and scaphoid abdomen 
seen in older children are often absent during infancy. For 
the purpose of illustrating the clinical course of a type of case 
the following description is given : 

There is usually a prodromal period in which a previously 
well child shows indications of ill health by a change in dis- 
position, loss of appetite, loss of weight, headache and consti- 
pation. It loses interest in its games and playmates, may 
become exceedingly irritable, hyperesthetic to light and noises 
and there may be a slight fever. Soon distinct symptoms of 
brain irritation set in ; these are notably headache and vomiting. 
The latter symptom if occurring without an indiscretion in 
diet, is very suggestive. The vomiting is usually of the pro- 
jectile type and is due to irritation of the meningeal branch of 
the vagus. Constipation is of the spastic type and the abdomen 
is flat or retracted. At this stage a slight rigidity of the neck 
may also be noted. The child grits its teeth during sleep and 
shows many other signs of cerebral irritation. 

Vasomotor disturbances present during this period are 
alternate flushing and paleness of the face, and the tache 
cerebrate, a broad red line produced by drawing the finger-nail 



326 DISEASES OF CHILDREN 

across the skin of the abdomen, persisting for a few minutes 
and indicating vasomotor paresis. 

With the progress of the meningeal inflammation the signs 
of increasing intracranial pressure make their appearance. 
Irregular innervation of various muscles supplied by the cranial 
nerves is a common symptom of this stage. To these mani- 
festations strabismus and twitching of the facial muscles belong 
most prominently. There is ptosis and the eyes are often fixed 
in a characteristic vacant stare. The accumulation of fluid in 
the ventricles is largely responsible for the pressure symptoms 
in the centres of the oculo-motor nerve. Likewise, the 
increased weight of the brain causes it to sag down upon the 
base of the skull and, by direct pressure upon the abducens, 
set up an inward deviation of the eyes. The deposit of miliary 
tubercles and inflammatory exudate upon the basal nerve roots 
tends to produce paralysis in the parts supplied by them. 
When the vagus and glosso-pharyngeus become finally involved, 
death results. 

Retraction of the head, opisthotonos, rigidity, twitching and 
automatic movements of extremities are the chief irritative 
manifestations of tuberculous meningitis. The most character- 
istic of these is the retraction of the head, which is a strong 
presumptive sign of basilar meningitis, although it is frequently 
seen in "cerebral" pneumonia. This symptom may also dis- 
appear in the later stage. Kernig's sign and Brudzinski's neck 
phenomenon can be demonstrated at this stage of the disease. 
In infants bulging of the fontanel is a prominent symptom. 

In infants emaciation is pronounced and progressive. Con- 
vulsions may occur, but they are not a constant feature. Like- 
wise, the shrill, piercing cry, "cri hydrocephalique," may or 
may not be heard. 

The final stage is that of paralysis in which the child becomes 
stuporous, the pulse is slow and irregular, the respirations are 
of Cheyne-Stokes type and the pupils are dilated and fail to 
react to light. Spasticity of the extremities and convulsive 



DISEASES OF THE NERVOUS SYSTEM 327 

movements are frequently seen. There is inability to swallow 
and emaciation progresses rapidly. The reflexes are abolished 
and urine and feces are passed involuntarily. 

The average duration of the disease is from two to three 
weeks; cases of meningitis persisting for four to 'Q.Ye weeks 
or longer are not likely to be tubercular in nature. 

The prognosis is always unfavorable. A few authentic cases 
of tuberculous meningitis which have recovered are on record 
but they are so exceptional that we should not build up false 
hopes for the curability of this disease. 

The diagnosis of tuberculous meningitis is based upon its 
gradual onset, the presence of the tuberculous diathesis or 
tuberculous family history; and the development during the 
early period of the disease of the characteristic symptoms, 
namely constipation, headache, slowing of the pulse, vomiting 
and drowsiness. In the later period the appearance of cranial 
nerve paralysis and choked disc makes the diagnosis more 
certain. 

Cerebrospinal meningitis is differentiated by its rapid onset 
and acute course; cerebral hyperemia by its transitory nature 
and hydro cephaloid by its association with diarrheal or other 
exhausting disease. The diagnosis can be corroborated by the 
examination of the cerebrospinal fluid, the characteristics of 
which are described under "Lumbar Puncture." When the 
tubercle bacillus cannot be demonstrated in the cerebrospinal 
fluid its presence may be definitely established by inoculating 
a guinea pig with the same. 

LUMBAR PUNCTURE. 

Lumbar puncture was introduced into clinical medicine by 
Quincke as a method of diagnosis in intracranial affections and 
it has become one of the most valuable methods of clinical 
diagnosis at our command. Furthermore, it has also opened 
up a most useful field in the treatment of cerebrospinal affec- 
tions. Owing to the continuity of the sub-dural space through- 



328 DISEASES OF CHILDREN 

out the entire cerebrospinal nervous system, it is self-evident 
that a specimen of fluid withdrawn from the lower end of the 
dural sac is identical in character with the fluid higher up in 
the spinal canal, and even within the cranium. Clinical experi- 
ence has proven this fact so reliable that we now place absolute 
dependence upon the cerebrospinal fluid obtained by lumbar 
puncture for information concerning spinal and intracranial 
pathological conditions. Even in the case of nervous syphilis 
more dependence is placed upon a Wassermann examination of 
the cerebrospinal fluid than of the blood. 

Technique. — The spinal cord proper terminates in the 
conus at the second lumbar vertebra where it divides into two 
coarse strands of fibres, which hug the lateral walls of the 
spinal canal. These bundles constitute the cauda equina and 
there is ample space between them for the safe introduction of 
a needle; besides, they are more or less movable and therefore 
not readily wounded. Therefore, a small trocar introduced 
between the spines of the third and fourth or fourth and fifth 
lumbar vertebrae, will enter the dural sac and the cerebrospinal 
fluid can in this manner be withdrawn easily and safely for 
purposes of clinical examination. 

The best instrument for performing lumbar puncture is the 
original Quincke needle. An aspirating needle — 10 cm. long 
and 1mm. in diameter — answers in the case of children. The 
operation must be performed under the strictest asepsis ; this 
applies to the operator's hands, the instrument, and to the skin 
at the site of puncture. 

It is not always easy to locate the different vertebra by at- 
tempting to count them from above downward, but if we re- 
member that a line drawn across the back on a level with the 
crests of the ilia will intersect the fourth lumbar interspace, 
it is a simple matter to select either this space or the one above 
it as the site for puncture. We may puncture as high as the 
second interspace, but there is not only an imaginary, but an 
actual advantage in selecting the lowest point, for as Sahli 



DISEASES OF THE NERVOUS SYSTEM 329 

was able to demonstrate, pus and other elements tend to gravi- 
tate to the lowest point, and when present in inconsiderable 
amount, clear fluid may be withdrawn from the second, while 
a cloudy one may come from the fourth interspace. 

The patient is turned on his right side, and the spinal col- 
umn bowed as much as possible by flexing the legs upon the 
abdomen and pressing down upon the buttocks, at the same time 
bending the upper portion of the back by downward pressure 
upon the shoulders. Care should be exercised not to exert 
pressure upon the neck, but always upon the shoulders. The 
spines of the vertebrae now stand out prominently and we are 
in a position to plunge between them into the canal. When the 
patient is comatose no anesthetic is required, and when partly 
conscious ethyl chloride should be used locally. In young 
children the laminae of the vertebra are horizontally placed 
and the interspinous ligament is not very firm. For this reason 
we can pierce directly between the spines and enter at a right 
angle to the spinal column. In older children the laminae are 
somewhat overlapping and the interspinous ligament is tough 
and firm. Here it is best to pursue the course originally recom- 
mended by Quincke, namely, place the point of the needle to 
the lower side of the median line and a little below the inter- 
space ; then direct the needle upward and inward, thus avoiding 
the ligament and at the same time slipping in between the 
laminae. In a child two years old the dural sac is penetrated 
when the needle is inserted for a distance of from 2 to 3 cm., 
in adults it must penetrate 4 to 6 cm. With a little practice 
we soon learn to recognize when the needle is in the spinal 
canal; there is no further resistance and the point can be freely 
moved. The stilet of the trocar is now removed and the first 
few drops of fluid are allowed to flow out; the remainder is 
caught in a sterile graduate, in order to estimate the quantity 
withdrawn. Ten cc. is sufficient for diagnostic purposes, but 
when the pressure is great we may withdraw as much as fifty cc. 
A portion of this can be used for making cultures or for 



330 DISEASES OF CHILDREN 

inoculating guinea pigs. The balance is studied microscopi- 
cally. The chemical examination is also important. 

The study of intracranial pressure is interesting, but of little 
clinical value in pediatric practice. For practical purposes we 
can estimate this sufficiently by the force with which the fluid 
flows from the canula. If a manometer be attached to the 
canula the pressure can be measured in mm. of mercury. The 
normal pressure in adults in the prone position is 5 to 7.3 mm. 
Hg. ; a pressure above 1 5 mm. Hg. is indicative of conditions 
such as meningitis and brain tumor (Sahli). 

Under normal conditions the fluid comes from the canula 
drop by drop. When the pressure is increased the drops come 
more rapidly and with considerable effusion it will spurt out 
in a stream. The stream is not steady and is affected by respir- 
ation. In tuberculous meningitis the pressure is higher and 
more fluid is obtained than in other forms of meningitis. In 
young infants the fontanel offers an additional means of esti- 
mating intracranial tension. 

The normal cerebrospinal fluid is clear, colorless and limpid. 
Its specific gravity varies between a little over 1000 to 1008. 
There is a trace of serum globulin, a copper reducing substance, 
presumably glucose, and salts. 

The copper reducing substance is usually absent in menin- 
gitis, either tuberculous or epidemic, while it is present in polio- 
myelitis. 

The admixture of blood may be due to the wounding of a 
vein and thus spoil the specimen for gross and microscopic 
study. It may, however, be due to hemorrhage into the cord 
or ventricles. 

In tuberculous meningitis the fluid is clear. If it is kept in 
a refrigerator for 24 hours a delicate fibrin mesh- work will 
form due to spontaneous coagulation of the fibrin present. This 
coagulum should be placed on a slide and dried and fixed, after 
which it should be stained for tubercle bacilli. By this proced- 
ure the tubercle bacillus can frequently be demonstrated. 



DISEASES OF THE NERVOUS SYSTEM 331 

In epidemic cerebrospinal meningitis the fluid is cloudy from 
the beginning, becoming more purulent with the progress of the 
disease. During convalesence and after serum treatment it 
begins to clear up. 

In poliomyelitis there is but a slight turbidity, the so-called 
"ground glass'' appearance being characteristic of this disease. 

In hydrocephalus the fluid is clear, although it contains some 
leucocytes. 

The cellular elements which are found in the cerebrospinal 
fluid are of distinct clinical significance, formally there is a 
cell count of but a few leucocytes to the cubic millimeter. In 
tuberculous meningitis there is a moderate increase of cells, 
mostly lymphocytes while in poliomyelitis there is a somewhat 
greater increase of the lymphocytes. In cerebrospinal menin- 
gitis polynuclear cells are found in great abundance. 

French writers lay great stress upon the predominance of 
lymphocytes in tuberculous meningitis. While the value of 
cytodiagnosis in cerebral inflammations is not without limita- 
tions, still a marked increase in lymphocytes over polynuclear 
elements is strong presumptive evidence in favor of a tubercu- 
lous infection. 

In purulent exudates ordinary cover-glass preparations 
stained with methylene blue are sufficient for the study of the 
bacteria present. Streptococci and pneumococci are recog- 
nized by their morphology while the micrococcus of epidemic 
cerebrospinal fever is a diplococcus similar in appearance to the 
gonococcus. The majority of these diplococci will be found 
within the pus cells. As Park puts it, the cells are crowded 
with the diplococci. 

Noguchi's globulin test is a valuable diagnostic aid in the 
study of the cerebrospinal fluid. It is present in the early 
stages of poliomyelitis and strongly positive in all forms of 
meningitis. It is also positive in nervous syphilis. For the 
technique of Noguchi's test the reader is referred to any work 
on clinical diagnosis. 



332 DISEASES OE CHILDREN 

The indications for lumbar puncture are any obscure cerebral 
condition in which there is clinical evidence of inflammation 
of the meninges or of intracranial pressure. So far its chief 
value has been that of a diagnostic aid, the importance of which 
cannot be questioned. Temporary relief of symptoms, and 
convulsions, has also attended its use, and in the control of 
uremic convulsions and coma it has proven of value. Compli- 
cations, such as pneumonia, contraindicate it. 

LETHARGIC, OR EPIDEMIC ENCEPHALITIS. 

Lethargic encephalitis is an acute infectious disease occur- 
ring epidemically which first attracted attention in 1917 when 
a number of cases were reported from Austria. In 1918 it 
broke out epidemically both in England and France and since 
that time it has been observed extensively in America. While 
children are affected with the disease, still it is more commonly 
observed in adults and, in this respect, differs from poliomyelitis 
which is characteristically a disease of childhood. 

The micro-organism, or virus causing epidemic encephalitis 
has not been isolated. Owing to the resemblance of the symp- 
toms to those encountered in botulism it was at first believed 
that the condition was the result of the poor food in the coun- 
tries directly affected by the World War. However, subsequent 
developments have definitely ruled out this factor as an etiologi- 
cal one. A relationship with influenza was also considered in 
the etiology of encephalitis because the first epidemic followed 
closely in the wake of the great influenza epidemic. 

Pathological studies of fatal cases have shown perivascular 
lymphocytic infiltration chiefly affecting the upper portion of 
the pons and the basal nuclei. These changes explain the pres- 
ence of the ophthalmoplegia and facial nerve involvement. 
There was no degeneration of ganglion cells as occurs in polio- 
myelitis. Many of the general manifestations of the disease 
must be explained on the basis of the associated toxemia. 

Symptoms. — The leading clinical manifestations of lethar- 



DISEASES OF THE NERVOUS SYSTEM 333 

gic encephalitis are drowsiness and stupor, whence the disease 
gets its name, associated with general muscular weakness and 
involvement of the eye muscles. While in typical cases third 
nerve and facial nerve paralysis are striking symptoms, still 
many atypical and incomplete forms are encountered as in the 
case of poliomyelitis, making the diagnosis difficult at times. 
When the characteristic focal lesions are present, ophthalmo- 
plegia or facial paralysis or both will develop. When, however, 
the pathological changes are not pronounced the general toxic 
features of the disease alone may be present. McNulty 
describes the following clinical types of epidemic encephalitis : 

1. Cases with general manifestations but without paralysis. 

2. Cases with third nerve paralysis. 3. Cases with facial 
paralysis. 4. Cases with spinal manifestations. 5. Cases 
with peripheral nerve involvement. 6. Abortive cases. 

The earliest cases of lethargic encephalitis occurring in chil- 
dren were reported by Batten and Still {Lancet, May, 1918), 
who called the condition epidemiic stupor in children. The 
chief symptoms were stupor from which the patient could be 
roused; muscular rigidity and tremor; mask-like expression of 
the face; nystagmus and inco-ordination of the eye muscles. 
There was no retraction of the head or disturbance of the 
reflexes. The cerebrospinal fluid showed nothing abnormal and 
the disease tended to recovery after the children had lain in the 
condition of stupor for several weeks, better reported a simi- 
lar epidemic occurring in the children of Paris and Neal 
{Archives of Pediatrics, June, 1920) has contributed an ex- 
haustive study of the cases occurring in New York City. 

Lethargy is the most striking and most constant symptom 
being encountered in the majority of cases. The patient is not 
completely unconscious and can be roused and often will answer 
questions intelligently but in a slow, hesitating manner. There 
is moderate fever in the beginning but this only lasts for about 
a week. Convulsions are rare. The cerebrospinal fluid is in- 
creased but it is clear and there is only a slight increase of 



334 DISEASES OF CHILDREN 

globulin and cellular elements. In this respect it differs from 
the fluid obtained in cases of poliomyelitis and meningitis. 

A peculiar type of encephalitis in children in which insomnia 
and mental disturbances dominate the clinical picture has 
recently been reported by Happ and Blackfan. Similar cases 
have been observed by other pediatrists since the above article 
appeared. 

The duration is protracted in the majority of cases, the symp- 
toms remaining stationary after their full development, for a 
period of several weeks and then gradually subsiding. Mild 
cases will run their course in from three to four weeks while 
the more severe ones may last as many months. The mortality 
is about 20 per cent, being lower than in the meningeal type of 
poliomyelitis. Death is usually due to bulbar paralysis. 

Diagnosis. — The gradual onset of the symptoms, namely, 
mental irritability followed by drowsiness and lethargy associ- 
ated with the development of an ophthalmoplegia should sug- 
gest encephalitis although tuberculous meningitis may present a 
similar clinical picture in its early stages. Lumbar puncture 
should always be performed both for its diagnostic as well as 
therapeutic value. The protracted course of the disease soon 
excludes tuberculous meningitis, and the absence of vomiting 
in the beginning of the disease speaks against meningitis. Po- 
liomyelitis is more abrupt in its onset, paralysis and signs of 
meningeal irritation are present as well as in meningitis (Ker- 
nig's sign; rigidity of the neck; exaggerated reflexes) while 
these symptoms are absent in encephalitis. 

Treatment. — The chief remedy for epidemic encephalitis is 
gelsemium. The symptoms upon which it is indicated are 
drowsiness; stupidity; tremulous weakness; extreme pros- 
tration and muscular weakness; occipital headache, moderate 
fever ; paralysis of the oculo-motor nerve. 

In the cases characterized by insomnia and mental symptoms 
belladonna is indicated. If the symptoms are not controlled by 
belladonna, hyoscyamus should be prescribed. For the late 



DISEASES OF THE NERVOUS SYSTEM 335 

manifestations and residual paralysis causticum is the most 
important remedy. Indications for other remedies which may 
be required in special cases will be found under the treatment 
of meningitis. Lumbar 'puncture seems to exert a beneficial 
influence over the course of the disease and should be systemati- 
cally performed at intervals of a week or less, according to 

indications. 

HYDROCEPHALUS. 

Hydrocephalus is a chronic idiopathic disease, in which there 
is an excess of cerebrospinal fluid in the cranial cavity (Hy- 
drops cerebri). The so-called acute hydrocephalus is a synonym 
for tuberculous meningitis and has no relationship to chronic 
hydrocephalus. 

There are two forms of the disease, namely, external hydro- 
cephalus and internal hydrocephalus. In the former there is 
a subdural accumulation of fluid, between the dura mater and 
the arachnoid. This is a rare form, almost invariably occurring 
secondarily to a congenital defect of the brain, meningeal 
hemorrhage, pachymeningitis, or atrophy of the brain. In the 
last instance the serous effusion occupies the space left vacant 
by the deficient brain, and it is spoken of as hydrocephalus ex 
vacuo. 

Chronic internal hydrocephalus is the commonest form of 
the disease, and the one usually referred to in speaking of 
hydrocephalus. The largest number of cases are congenital. 
The head may be so large at full term as to impede delivery, 
or the effusion be but trifling and accumulate so slowly that the 
head does not become noticeably enlarged until several weeks 
after birth. A slight degree of enlargement of the head is noted 
in most cases at birth but in some instances it may be so slight 
that it escapes notice and the condition is not recognized clin- 
ically until the child is several months old. 

Internal hydrocephalus is almost invariably a primary con- 
dition. In rare instances it is found associated with tumors of 
inflammatory processes at the base of the brain when such con- 



336 DISEASES OF CHILDREN 

ditions cause obstruction of the foramen of Magendie or obliter- 
ate the communications between the ventricles of the brain. 
Accumulation of cerebrospinal fluid in the ventricles may re- 
sult from diminished resistance of the cranial walls, and also 
from causes directly increasing the blood-pressure in the brain, 
i. e., whooping-cough, bronchitis, emphysema and convulsions. 
Such conditions however are transient and rarely lead to a 
permanent hydrocephalus. The head is enlarged in rickets, 
owing to the abnormal softness of the cranial bones and the 
malnutrition but here again true hydrocephalus is rare. In 
congenital syphilis, however, a moderate degree of hydroce- 
phalus is one of the characteristic clinical manifestations of the 
disease. Under specific treatment improvement usually occurs 
which unfortunately does not take place in idiopathic hydro- 
cephalus. 

The brain is greatly distended, the convolutions become ob- 
literated and the cortex may become a mere shell or the brain 
appear as a large cyst. The cranial bones are thin and the 
sutures widely separated; supernumerary bones are commonly 
found. In rare instances premature ossification of the cranium 
occurs with hydrocephalus. .Spina bifida and other congenital 
defects may be found associated. The amount of fluid varies 
from several pints to more than a gallon. It resembles the 
normal cerebrospinal fluid. 

The lateral ventricles show the greatest amount of distention. 
In about half of the cases the communication with the spinal 
subdural space is obliterated and a lumbar puncture will prove 
negative when this is the case. The third and fourth ventricles 
likewise will either be found normal or distended according to 
whether the choroid plexuses are normal or sufficiently enlarged 
to occlude the ventricular aqueducts. 

Symptoms. — The head is rounded, its size much out of 
proportion to the rest of the body and in its relation to the 
development of the face, and the fontanels and sutures are 
wide open and tense. In external hydrocephalus the enlarge- 



DISEASES OF THE NEKVOUS SYSTEM 337 

ment is usually not so pronounced, and when the skull is still 
soft fluctuation may be elicited over the head. 

It is necessary to remember the normal circumference of 
the head at different periods of infancy in order to determine 
whether the head be abnormally large. At birth this is about 
fourteen inches, and at the end of the first year nineteen inches. 
Beside this, the relationship of the circumference of the head 
to the chest is important to bear in mind, the circumference of 
the head at birth exceeding that of the chest by half an inch; 
later, during the entire period of infancy, the two measurements 
are practically equal. From these data it is easy to determine 
an abnormally developing head. Every cranial enlargement 
does not, however, indicate hydrocephalus, the most important 
condition to be differentiated being rickets. Hydrocephalus 
may occur without enlargement of the head. In such cases there 
is either premature ossification of the skull or a late onset of 
the disease. They are generally idiots and die early (Holt). 
It is impossible to recognize this condition during life. 

The rate at which the head enlarges varies greatly ; the earlier 
and more rapidly the enlargement develops the more serious is 
the prognosis. Cerebral symptoms are slight, often entirely 
wanting. The development of the child is, however, much re- 
tarded, and the majority of cases die early of marasmus. Those 
surviving this period die in early childhood, as a rule, from 
some intercurrent disease. The mind becomes affected and 
many are idiots. They are irritable and often show evidence 
of violent temper. In others, again, the intelligence is but 
slightly interfered with and they may live even to reach adult 
life, being, however, both physically and mentally retarded in 
development and helpless on account of the great weight of their 
head. A moderate degree of hydrocephalus is not incompatible 
with normal mental development. Some cases evidently become 
arrested and grow up as normal individuals with an abnormally 
large head of the characteristic shape and show average intelli- 
gence. 
23 



338 DISEASES OF CHILDEEN" 

The differential diagnosis between hydrocephalus and 
rickets should present no difficulties. The hydrocephalic head 
is enlarged out of all proportion to the rest of the body and 
presents a regular rounded outline. The eyes are deflected 
downward, so that the lower lid crosses the iris higher than 
normal. The outline of the skull is globular and the forehead 
is prominent and bulging. The face is small in comparison 
with the head. The fontanels bulge and pulsate, and the 
sutures are widely separated, while the cranial bones feel thin. 
The veins of the scalp are prominent and distended, owing to 
interference with the return circulation of the brain. Nystag- 
mus and strabismus are frequently noted. Optic nerve atrophy 
is also noted in some cases as a late development. In rickets, 
on the other hand, the head is square and the centres of ossifica- 
tion in the frontal and parietal bones are hypertrophied. The 
skull is hard excepting in the occipital region, where craniotabes 
may be present. Enlarged epiphyses and deformities in the 
extremities are associated. 

The treatment is unsatisfactory. Up to the present time no 
form of either medical or surgical treatment has proven itself 
to be of any distinct benefit. Mercury and potassium iodide 
should be used in all cases seen early and a certain percentage 
of cases will be benefited by these remedies but every case is 
not specific and does not, therefore, respond to this treatment. 

Bartlett (Goodno's Practice) mentions some cures effected 
by the application of solar heat, which is a harmless measure 
that may at least be tried. "The method consists in exposing 
the child's occiput to the direct rays of the sun for twenty min- 
utes each day, gradually increasing the duration of the seance 
until the limit of thirty or forty minutes is reached. It is be- 
lieved that the local sweating acts to remove a portion of the 
effusion, while the thermic heat aids nutrition." Strapping the 
head with adhesive plaster; repeated tappings of the lateral 
ventricles; tappings followed by the injection of iodine; drain- 
ing the ventricles into the areolar tissue of the scalp are some of 



DISEASES OF THE NERVOUS SYSTEM 339 

the surgical methods which have been tried and are advocated 
by some surgeons. 

CONVULSIVE AFFECTIONS. 

Eclampsia, or Infantile Convulsions. — General convul- 
sions are of common occurrence in infants of the spasmophilic 
diathesis (see "Spasmophilia"). Apparently insignificant 
causes like teething can precipitate a convulsion in such infants. 
Rickets also predisposes to convulsions. Infants and children 
in whom there is no evidence of spasmophilia may have convul- 
sions from conditions which are, however, of a more serious 
nature. Thus, acute infectious diseases are frequently ushered 
in with convulsions. In meningitis, encephalitis, hydrocephalus 
and brain tumor, convulsions occur symptomatically. Idio- 
pathic convulsions in older children are usually epileptic in na- 
ture. Convulsions occurring in the newborn are frequently due 
to cortical irritation from a birth injury. The status lymphati- 
cus may be the cause of a fatal convulsion. 

The anatomical lesions found in children dying in convul- 
sions are by no means constant or characteristic. The changes 
occurring in the brain are probably anemic, followed by venous 
hyperemia. When intense congestion, serous effusion and 
punctate hemorrhages are found after death they are to be 
looked upon as a result of the convulsion and not as a cause of 
the same, death having resulted from asphyxia. The initial 
stage of a meningitis may also be found ; or, if the convulsion 
depends upon organic brain disease, such a condition becomes 
evident. In some instances the anatomical findings of the 
status lymphaticus are present. 

Symptoms. — Infantile convulsions are most frequently gen- 
eral although a localized or partial convulsion may result as 
well from reflex irritation as from organic disease. In such 
cases the subsequent course of the disease must be followed 
before a final diagnosis can be made. True local convulsions 
or Jacksonian epilepsy, repeatedly commence in one extremity 



340 DISEASES OF CHILDREN" 

and if they do not remain local, at least continue so for an 
appreciable time (Herter). This form of convulsion is indica- 
tive of organic disease, the nervous discharge commencing at 
the seat of irritation. With it there is no loss of consciousness. 
Prodromal symptoms are therefore usually present, indicating 
the commencement of a general convulsion. They may be so 
slight as to be entirely overlooked, or they may manifest them- 
selves as extreme restlessness, twitching of the mouth, eyelids, 
extremities, and rolling of the eyes. 

The convulsion proper is very similar to an epileptic fit. 
The child becomes suddenly rigid, the head being thrown back, 
the hands clenched, with thumbs buried in the palms, and the 
extremities stiffen out. This stage is only of short duration, 
not as long as in a true epileptic attack, while the succeeding 
stage, consisting of intermittent spasmodic contractions of the 
extremities, is comparatively longer. During this stage the 
entire body is seen to take part in alternate rhythmical contrac- 
tion and relaxation. The child is unconscious, and may invol- 
untarily pass both urine and feces. In the course of a few 
minutes to half an hour, according to the gravity of the case, 
the spasms gradually subside, leaving the child in a soporous 
condition. It is not uncommon for several convulsions to occur 
in succession, as repeated convulsive seizures create a suscepti- 
bility from which the nervous system recovers itself with 
difficulty. 

Prognosis. — This depends upon the nature of the exciting 
cause and the course pursued by the seizure. When convul- 
sions recur in rapid succession, or when associated with laryn- 
gismus stridulus, the prognosis becomes grave. Likewise in 
convulsions occurring with uremia or with meningitis, exten- 
sive hemorrhage, or other serious intra-cranial lesion, the prog- 
nosis is grave. Should the convulsive habit become firmly estab- 
lished, there is danger of epilepsy developing. When the con- 
vulsions are unmistakably due to spasmophilia the prognosis 
is good as this condition is amenable to treatment. 



DISEASES OF THE NERVOUS SYSTEM 341 

Diagnosis. — The differentiation of symptomatic from idio- 
pathic eclampsia rests upon a proper examination of the patient 
for evidence of disease elsewhere. Thus, with convulsions 
ushering in the infectious fevers, there are always the symp- 
toms belonging to the stage of invasion of the particular fever 
in question. Convulsions are quite common with the onset of 
pneumonia, especially apex pneumonia. In uremic convul- 
sions the urine establishes the diagnosis. Those due to reflex 
irritation give evidence of such a source of irritation, and 
purely spasmophilic and rachitic cases show evidence of these 
conditions. Intra-cranial disturbances are recognized by char- 
acteristic neurological findings which can be demonstrated 
both before and after the convulsions have occurred. 

Convulsions occurring shortly after birth are usually due to 
meningeal hemorrhage. Unilateral spasms may occur from 
cortical hemorrhage, as a result of whooping-cough, trauma of 
idiopathic origin. 

Epilepsy is to be suspected when repeated convulsive seizures 
occur in children over three years of age, notwithstanding the 
absence of any source of reflex irritation or a toxic cause for 
the attack. Other symptoms, such as an aura and stigmata of 
degeneration, are usually ascertainable. 

Treatment. — All exciting causes must be removed at once 
whenever this is possible, and the predisposing cause is to be 
overcome by attending to the child's general condition. Con- 
stitutional and dietetic treatment together with an abundance 
of fresh air and sunshine, are indispensable here. (See Rickets 
and Spasmophilia.) 

As gastro-intestinal irritation plays such an important role 
in the precipitation of convulsive seizures, the bowels should 
at once be emptied when the attack is suspected to arise from 
this source. 

During the seizure every article of clothing should be loose- 
ened. If the convulsion lasts for any considerable length of 
time a warm bath, together with cold applications to the head, 



342 DISEASES OF CHILDREN" 

is indicated. In long-continued or recurring convulsions a hot 
pack may be resorted to. 

The most frequently indicated remedies are Belladonna, 
cuprum, ignatia and magnesia phos basing our prescription 
purely upon the occurrence of convulsions. But when the con- 
vulsion is symptomatic, the results of treatment will be more 
satisfactory if we direct our attention to the exciting cause 
instead of looking upon the convulsion as an independent dis- 
ease. In some instances it becomes necessary to check the con- 
vulsions when they recur at dangerously frequent intervals by 
giving a rectal dose of chloral hydrate or potassium bromide. 

Bell. — Convulsions, with flushed face; dilated pupils; 
cerebral congestion; throbbing carotids; pyrexia. Indicated 
in those cases ushering in the infectious fevers, in some reflex 
convulsions, and in convulsions occurring in the early stages 
of meningitis. 

Cuprum. — Convulsions beginning in the fingers and toes, 
becoming general, with marked cyanosis. Spasm of the glottis 
is associated with these cases. Convulsions occurring during 
the eruptive fever when the rash disappears ; whooping-cough ; 
meningitis. Cuprum ars. is more valuable in uremic con- 
vulsions. 

Cina. — Reflex convulsions from irritation of the intestinal 
tract, whether due to worms or not. The spasmodic movements 
are often confined to the eyes and face, continued with irregular 
jerkings of the extremities. In this respect it is similar to 
chamomilla, which presents many of the premonitory symp- 
toms of eclampsia, the child being feverish, irritable, and 
suffering with intestinal colic or painful teething. In such 
cases chamomilla will frequently ward off a convulsion. 

Cicuta. — The convulsion comes on suddenly without premon- 
itory signs. The stage of tonic spasm is well marked, and the 
child may remain rigid for a long time, only a few jerks of 
the extremities being noticed during the attack. Cicuta is 
especially indicated in convulsions occurring in cases of cere- 
brospinal meningitis. 



DISEASES OF THE NERVOUS SYSTEM 343 

Ignatia. — Convulsions in nervous subjects brought on by 
fright or peripheral irritation. The vascular excitement of 
belladonna is not present in these cases, and the face is pale 
instead of hot and flushed, as in the latter remedy, Neurotic, 
hysterical children. 

Magnesia phos. — Idiopathic convulsions; defective nutrition 
of the nervous system; spasmophilia. (See Epilepsy.) 

Opium. — Convulsions in cerebral hemorrhage. There is 
trembling of the whole body ; purplish color of face ; stertorous 
breathing and sopor; post-epileptic stupor. 

EPILEPSY. 

Idiopathic epilepsy is a chronic disease characterized by the 
occurrence of attacks of unconsciousness with general convul- 
sions (grand mal) or by recurring attacks of momentary loss of 
consciousness alone (petit mal). 

Etiology. — Heredity plays a prominent role in the etiology 
of epilepsy. The family history may reveal the existence of 
epilepsy, insanity or some other serious nervous affection in the 
parents or near blood relations. Parental syphilis and alcohol- 
ism are also looked upon as etiological factors. In many in- 
stances a history of convulsions in infancy and early childhood 
is obtained. 

Many epileptics show the stigmata of degeneration to a 
marked degree. They may be vicious and criminally inclined or 
are intellectually and morally defective. Startling exceptions 
in the form of geniuses, are observed. As to age, the period of 
puberty furnishes the majority of cases. It only rarely develops 
before the third year. Sachs (The Nervous Diseases of Child- 
ren) is of the opinion that hereditary (idiopathic) epilepsy is 
not as common as is generally supposed, many cases being 
accepted as such because a former cerebral lesion or a trauma- 
tism to the head has been overlooked owing to the disappearance 
of the paralysis and other symptoms due to such a lesion, from 
which, however, the epilepsy springs. To this category belong 



344 DISEASES OF CHILDREN 

those cases of epilepsy associated with infantile cerebral palsies 
and defective development of the brain. 

The exciting cause of the seizure is most often found in 
disturbances of the digestive tract. Overeating is a common 
factor. Acute indigestion, either through reflex irritation or 
auto-intoxication, will frequently precipitate an attack. Reflex 
irritation from phimosis, eyestrain, worms, etc., exerts a similar 
influence. Emotional excitement, excessive physical exertion, 
and poorly ventilated or crowded apartments are most disad- 
vantageous to the epileptic. In several of my cases the first 
seizure developed after a slight traumatism, the psychic effect 
no doubt being more to blame than the accident itself. 

A constant pathological lesion is not found. Judging from 
our knowledge of the physiology of the brain and the symptoms 
produced by irritation and organic disease of the cortex in the 
Rolandic area, it is reasonable to suppose that the pathologic 
condition is located here. Indeed, a number of observers, 
notably Van Giesen and Bleuler, have demonstrated changes 
in the cortical cells and in the neuroglia. Lesions in the basal 
ganglia have also been described. These are probably in the 
nature of secondary changes. Many cases show evidences of the 
status lymphaticus. 

Symptoms. — An* attack of petit mal is characterized by a 
momentary loss of consciousness, unaccompanied by convulsions 
or other nervous phenomena. In children it is often looked 
upon as mere absent-mindedness or a fainting spell; in older 
subjects it is more likely to be confounded with vertigo, with 
which, it is unnecessary to say, it has nothing in common. 
After this condition has once been fully established, a change 
in the child's mentality becomes manifest; it may go over into 
the convulsive form or exist in conjunction with the same. 

Besides petit mal there are numerous other forms of incom- 
plete seizure, all, however, attended by momentary loss of 
consciousness. There may be merely twitching of certain 
muscles, notably in the arm and face; a sudden impulse to run 



DISEASES OF THE NERVOUS SYSTEM 345 

forward or perform other automatic movements, of which the 
patient is unconscious. Sometimes coma exists without convul- 
sions, or the child may have aurse for a long time before the 
convulsions make their appearance. There are also certain 
psychic equivalents of the epileptic seizure, in the form of 
maniacal and other insane acts. Following the fit, the patient 
may for several days perform acts for which he is irresponsible. 
An attack of grand mal is very similar to an attack of 
infantile convulsions. Other symptoms, however, which are not 
found with ordinary convulsions are present and the various 
stages are more sharply defined and characteristic. The fol- 
lowing stages are to be observed : 

(1) The aura, or prodromal stage. This usually consists of 
a sensory disturbance, which may be variously described as 
a tingling ; feeling of numbness ; crawling ; sensation of a gust 
of wind directed upon the affected part : hallucinations of sight, 
smell and hearing. There may also be motor disturbances, and 
the character of the aura will in many instances point to involve- 
ment of a special area of the cerebral cortex. 

(2) The initial cry. This marks the commencement of the 
stage of tonic spasm. The patient utters a loud cry, as a result 
of the spasmodic contraction of the respiratory muscles forcing 
the air through the partially closed glottis, whereupon he loses 
consciousness and falls to the ground. 

(3) The tonic spasm. During this stage the body is perfectly 
rigid, the legs extended, the arms flexed and the hands clenched, 
the thumbs being pressed into the palms of the hands. The head 
may be retracted, as in opisthotonus (young children), or it may 
be drawn to one side, the eyes being fixed and pointing in the 
same direction. The pupils are immovably dilated. The face, 
at first pale, now becomes reddened, and even cyanotic, if this 
stage is prolonged. The jaws are set, and! the tongue is 
frequently caught between the teeth. The stage of tonic spasm 
lasts for a period of about a minute, at the end of which time it 
gradually subsides, being followed by — 



346 DISEASES OF CHILDREN 

(4) The stage of clonic spasm. This consists of alternate 
relaxation and contraction of the muscles of the extremities and 
thorax, persisting for several minutes (seldom over five min- 
utes). Through these movements the body is thrown into violent 
action, and frothy saliva is ejected from the mouth, the tongue 
quite frequently being caught between the teeth and badly bitten. 
Urine and feces are frequently passed involuntarily. The 
movements gradually subside and the patient goes over into — 

(5) The stage of stupor. Post-epileptic stupor is a profound 
sleep from which the patient may be temporarily aroused, but 
soon relapses into unconsciousness. This may last for several 
hours. The pupils are dilated. 

Prognosis. — It is the concensus of opinion among neurol- 
ogists that true epilepsy is an incurable disease. Some cases of 
a mild type which have received early care and treatment may 
recover. Spontaneous recovery also may occur in rare instances 
and cures through surgery have been reported although the fail- 
ures are too frequent to give surgery much credit. The best 
results that we can expect from treatment are a reduction in the 
number of seizures and the general improvement of the patient's 
physical and mental condition. 

Diagnosis. — Eclampsia : Prior to the age of three years ; the 
convulsions are of longer duration and signs of rickets or spas- 
mophilia can be demonstrated. Eclampsia responds to dietetic 
and constitutional treatment while this has little effect on true 
epilepsy. 

Hysteriod convulsions are usually precipitated by emotional 
excitement; rigidity is marked, followed by irregular move- 
ments of the extremities ; the duration is much longer than an 
epileptic seizure, and there is no biting of the tongue or in- 
voluntary micturition and defecation (Gowers). 

Other conditions to be thought of are uremic and other toxic 
convulsions, and, in the case of petit mal, syncope and vertigo 
must be excluded. 

We may be called upon to make a diagnosis in a case where 



DISEASES OF THE NERVOUS SYSTEM 347 

the occurrence of convulsions is not known. Thus, we may 
find a patient in post-epileptic coma, or have to deal with a case 
of nocturnal epilepsy where the convulsions have taken place 
unobserved. Post-epileptic coma is distinguished from uremia 
by the presence of dilated pupils and the absence of albumin- 
uria and casts in sufficient amount to indicate nephritis. The 
tongue should be carefully examined for scars. Strumpell 
lays stress upon a careful inspection of the conjunctiva and 
face for punctate hemorrhages. When these are seen in a 
patient who awakens in the morning dull and confused we 
have strong presumptive evidences of nocturnal epilepsy. When 
this is associated with enuresis the presumption is still stronger. 
Besides, in forming an estimate of the true nature of any 
condition associated with disturbed or temporary loss of con- 
sciousness the family history, the child's mental development 
and the presence of stigmata of degeneration play an im- 
portant role. 

Treatment. — All sources of reflex irritation, such as phi- 
mosis, cicatrices, errors of refraction and nasal defects must 
be corrected. The diet is of great importance. The patient 
should be kept mainly on a vegetable diet, allowing milk reg- 
ularly, and poultry and fish occasionally; furthermore, the 
stomach must never be overloaded, and, besides prohibiting 
meat, all indigestible articles of food, such as pastry, rich 
desserts, etc., must be strictly avoided (Bartlett). 

In cases of malnutrition, meat may occasionally be allowed, 
but a liberal meat diet is always injurious to the epileptic. 
Cases in which convulsions had ceased under an exclusive 
vegetables and milk diet invariably relapsed when meat was 
allowed, no change in the medicinal treatment having been 
made (Thompson, Practical Dietetics). Cod liver oil is indi- 
cated in the rachitic and strumous. 

It is a noteworthy fact that an excess of indican is found in 
the urine of many epileptics just about the time of the seizure 
(Herter), being formed in the intestines from the excessive 



348 DISEASES OF CHILDEEN 

putrefaction of proteids. This points to the necessity of pre- 
venting intestinal putrefaction, which may be at least par- 
tially accomplished by careful regulation of the diet. Indica- 
nuria is produced not only by the indigestion of albuminous 
food, but also as a result of muscular atony of the stomach and 
sub-acidity. As the lactic acid bacillus is antagonistic to the 
colon bacillus, and should in fact predominate over the latter in 
the small intestines in childhood, it is readily seen why a milk 
diet and the prohibiting of meat is so beneficial in epilepsy. 

Excessive physical exertion must be avoided, while judi- 
cious out-of-door exercise proves of the greatest benefit. 

During an attack the patient should be protected from in- 
juring himself. A towel or other available article may be 
inserted between the teeth to prevent biting the tongue, and 
the clothing should immediately be loosened. The inhalation 
of amyl nitrite sometimes shortens the attack. 

The best therapeutic results are obtained from remedies 
selected upon general indications, taking into consideration the 
patient's mental, temperamental and diathetic peculiarities; 
also, any disturbances in the alimentary, respiratory, genito- 
urinary tract, etc. For this reason such remedies as cicuta, 
hydrocyanic acid, omanthe crocata and solawum are rarely 
of positive value. On the other hand, argentum nitr., calc. 
carb. and phos., lycop., nux vomica, pulsatilla, silica and 
sulphur are of service. Magnesia phos. 3x trit. has proven 
clinically useful in a number of cases of epilepsy. 

Where disorders of the digestive tract and lithemic symp- 
toms are prominent conditions nux vom. } lycopodiwm, cina and 
sepia stand out prominently. 

In petit mal I have obtained good results from cannabis 
indica in small doses. The seizures occurred less frequently 
and the child's general condition was improved. Another 
remedy from which I have obtained results and practically use 
as a routine in beginning the treatment of any case is santonin. 
Whether or not worms are present, santonin certainly is help- 



DISEASES OF THE NEEVOUS SYSTEM 349 

ful in many cases of intestinal toxemia and its empiric use in 
epilepsy is frequently followed by good results. 

The following resume is given in order to call attention to 
the guiding indications for the important remedies : 

Arnica. — Recent traumatic cases. 

Arg. nitr. — Old-looking face, pupils dilated before paroxysm 
for a day or two, flatulent dyspepsia with cardiac palpitation, 
apprehensiveness and depression of spirits, attacks of hemi- 
crania, periodic trembling of body and paralytic weakness, 
epilepsy from fright, masturbation, menstrual difficulties. 

Arsen. — Anemic, weakly subjects. Burning in the spine, 
burning in the stomach and bowels after eating, diarrhea with 
smarting about anus. Petit mal. 

Bell. — Violent convulsions, with marked cerebral conges- 
tions; mania. Prodromal symptoms consist of flushing of the 
face, throbbing of the carotids ; wild, staring expression ; feel- 
ing of suffocation. During the interval, throbbing headache, 
vertigo, flushing of the face with burning heat, easily fright- 
ened, night terrors, enuresis. Stramonium is similar in many 
respects. Symptoms brought on by fright, with great nervous 
excitement; spasmodic constriction of the throat, gyratory 
movements of extremities and threatened convulsions. Stram- 
onium is frequently of service when belladonna has failed to 
give relief, or its chances for doing good have slipped by, as 
it is of no service in old cases. The cases in which hyoscyamus 
has proven so beneficial are undoubtedly hysterical in nature, 
as Jahr intimates. Such causes as "disappointed love, jealousy, 
and grief/ 7 mentioned under the etiology of hyoscyamus, point 
to the hysterical element in these attacks, as also such symp- 
toms as " attempts at swallowing fluids renew the attacks," and 
"inclined to talk a great deal after the attacks ; slight wander- 
ing of the mind." 

Bufo. — Bo j anus (Die Horn. Therapeutik in Hirer Anwend- 
ung auf die Operat. Cliirurg., 1880) reported a series of 
twenty-two cured cases of epilepsy, among which four were 



350 DISEASES OF CHILDREN 

cured by the use of bufo alone, three with bufo followed by 
salamander, and two with bufo in conjunction with lachesis 
and ignatia. He gives no special indications for this remedy. 
"After fright or onanism; attacks at night, followed by some 
hours of coma; loss of consciousness and falling down; tonic 
and clonic spasms; turgescence and distortion of face; bites 
tongue; involuntary emission of urine; the lower extremities 
are more in motion than the upper ones.' 7 — (C. G. R.) 

Calc carb. — Scrofulous diathesis and leucophlegmatic tem- 
perament. Anemia; catarrhal and cutaneous affections; 
prominent belly; cold hands, sweaty feet; sweating about the 
head. "Frequently indicated after sulphur/'' or in conjunc- 
tion with belladonna. 

Cannabis Indica. — Clinically useful in petit mal. Allen 
(Handbook of Materia Medico) gives the following symptoms : 
Absent-minded, forgetful of what he intended to write or speak 
so that he cannot finish a sentence ; forgetful of his last words 
and ideas. Unconsciousness every few minutes. Misapprehen- 
sions concerning time and space. 

Causticum. — Where the mind is affected and paralytic affec- 
tions are associated with the epilepsy. Degenerative changes 
in the nervous system. Paralytic weakness after the seizure 
is marked. 

Cicuta. — Violent epileptiform spasms, accompanied by 
puffed, bluish face ; fixed, staring eyes ; terminating in trem- 
bling and long-continued sopor. Intestinal irritation, with 
venous congestion of abdomen. 

Cimicifuga rac. — Epilepsy associated with disturbances 
in the female generative organs. 

Cina and santonin are useful in most cases. Ridding the 
intestinal tract of parasites is one of the first things to be 
thought of in epilepsy in children. Besides the symptoms 
directly referable to worms there are a number of others calling 
for cina, particularly those referable to the disposition, the 
appetite and general nutrition. 



DISEASES OF THE NEEVOUS SYSTEM 351 

Cuprum. — Clear, idiopathic cases without organic lesions. 
The attacks may have been precipitated by fright, mental 
excitement, or suppressed exanthemata. Nocturnal epilepsy. 
The attack is typical, and cyanosis is usually marked. 

Gels. — Dull occipital headache before attack; languor; droop- 
ing of eyelids ; easily frightened into diarrhea ; prolonged spasm 
of the glottis during attack. 

Ignatia. — This remedy is especially suited to ordinary cases 
of epilepsy in children. They are exceedingly nervous and 
easily frightened, irritable and peevish, and difficult to control. 
Jahr considered it the most valuable remedy with which to begin 
a case. 

Indigo. — Depression of spirits. Excitable, furious and 
easily angered before the attack. Melancholy, timid or gloomy 
after the attack (L. M. Kenyon). From the isopathic stand- 
point, indican in homeopathic doses might prove useful. 

Nux vom. — Indigestion with attacks of canine hunger; 
constipation, tongue coated posteriorly, bad taste, headache on 
rising in morning, with irritability (lycop., great irritability 
after sleep) and anorexia, especially mornings. Nux vom. and 
lycop, are very important general remedies for the epileptic. 

Opium. — Prolonged post-epileptic stupor. Nocturnal cases, 
with mental derangements. 

Silica. — Lack of animal heat; strumous and rachitic dia- 
thesis ; neurasthenia ; pale, transparent skin ; profuse sweat after 
the seizure. "Epilepsy, the aura begins in the solar plexus. 
Chronic effects of fright and nervous shock. Great irritability ; 
constant restlessness" (T. P. Allen). 

Sulphur. — Scrofulous or exudative diathesis. It is unneces- 
sary to describe the characteristic sulphur child here. Sulphur 
is also important as an intercurrent, or in cases not responding 
to the usual list of remedies. 

Bromides- — The administration of bromides in epilepsy 
should not be a routine procedure but should only be resorted to 
when other measures fail to keep the number of seizures within 
safe bounds. 



352 DISEASES OF CHILDREN 

"It is certain that very few cases have been permanently 
cured by the administration of bromides; but unquestionably 
they serve an admirable purpose in checking the number of 
attacks and in diminishing their severity. To accomplish this 
end the bromide salts should be administered according to< a 
definite plan. It has been my practice to give preference to the 
bromide of sodium,, which I employ, according to the age of the 
patient, in ten or fifteen-grain doses, three times a day. If 
given in a wineglassful of (alkaline) water after meals the 
gastric functions will not be seriously impaired. ... In the 
case of nocturnal attacks the medicine should be given before 
going to bed (the entire daily dose), and at no other time." 
— (Sachs, Nervous Diseases of Children.) The method rec- 
commended by Seguin {New York Med. Jour., March, 1890) 
has many followers. It consists in the administration of the 
larger part of the full daily dose shortly before the time when a 
seizure is to be expected. During the interval a much smaller 
dose is employed, and the bromide is always given highly 
diluted. 

According to Bayley, the bromide of strontium is less irri- 
tating, produces less acne and has seemed to him more 
satisfactory in results than those obtained from the sodium or 
potassium salt. He gives from ten to sixty drops of a saturated 
solution (each drop representing about % grain of the salt) 
after meals, well diluted. If favorable effect is noted, sufficient 
dosage is maintained to stave off the paroxysms. It has been 
claimed recently that the action of the bromides is augmented 
and that therefore the dose can be reduced if we entirely inter- 
dict the use of table salt at the time the patient is taking 
bromides. 

As soon as the paroxysms are controlled the dose is decreased 
to a minimum, but the remedy should not be withdrawn 
immediately. 



DISEASES OF THE NERVOUS SYSTEM 353 

CHOREA. 

Chorea, or St. Vitus' dance, is one of the commonest nervous 
diseases of childhood. It is a neurosis characterized by the 
presence of irregular, purposeless, involuntary muscular con- 
tractions in various parts of the body, usually of wide distribu- 
tion, and associated with a loss of muscular tone and disturbed 
co-ordination of voluntary movements. The onset is acute and 
the course pursues a sub-acute character. The relationship of 
chorea to rheumatism is one of its most noteworthy features. 

Etiology. — There are evidently two classes of chorea. In 
the one we can find no evidence of rheumatism or endocarditis. 
This form is encountered in delicate and neurotic children and 
usually develops as a result of insufficient fresh air, rest and 
proper diet in conjunction with the strain of school life. The 
first symptoms of chorea may develop after a fright or some 
emotional shock. For this reason we see so many cases de- 
veloping in the spring of the year; in other words, towards 
the close of the school term. In every children's clinic 
the large number of pale, thin, ambitious children, mainly 
girls, that come regularly with symptoms of chorea in March 
and April stands in distinct contrast to the scarcity of these 
cases in the fall. 

Hodge has shown that as a result of fatigue the nerve cells 
shrink in size, their nuclei and nucleoli become shrivelled and the 
lenticular granules of the protoplasm, probably nutrient, dis- 
appear. While under ordinary conditions the cell is promptly 
restored to normal after a period of rest, a much longer time, 
and sometimes a protracted period of rest, is required for this 
restoration in anemic, neurotic children. 

Griesbach's interesting experiments with the esthesiometer 
have given valuable data in the study of school-fatigue in 
children. When this method of investigation shows that recup- 
eration is sub-normal in a given case we should accept this as 
a danger-signal, for if fatigue is prolonged it becomes cumu- 
24 



354 DISEASES OF CHILDREN 

lative and then complete recuperation is impossible so long as 
the child is kept at school (La Fetra). 

In the other class of cases the etiological factor is distinctly 
a rheumatic infection. Rheumatic manifestations (arthritis 
and endocarditis) may precede, co-exist with or follow the 
choreic attack. 

Streptococci have been isolated from the blood and nervous 
system in a few fatal cases of chorea by Westphal and by 
Wassermann ; tonsilitis has also been observed to precede attacks 
of chorea, as in rheumatism. 

The opponents of the rheumatic theory of the etiology of 
chorea have been misled to a certain extent by a failure to 
•understand the clinical course pursued by rheumatism in the 
child. If we remember that rheumatic infection does not 
necessarily mean polyarthritis, but that certain forms of sore 
throat; vague joint pains or pains in the muscles and tendons 
accompanied by fever ; growing pains and primary endocarditis 
itself are all manifestations of a rheumatic infection in child- 
hood we will concede a much higher percentage of rheumatism 
in our choreic patients than otherwise. Heubner, makes the 
rather sweeping statement that chorea is the commonest form 
of rheumatism in childhood. 

Chorea is also closely associated with a rheumatic family 
history. In the cases in which I was unable to ascertain 
definite symptoms of rheumatism in the child there was almost 
invariably evidence of the disease in the parents or in other 
members of the family. From this it would seem that a common 
toxic agent exists which is capable of giving rise to choreic 
manifestations if it affects principally the cerebral cortex, and 
rheumatic manifestations if the articulations and serous mem- 
branes are attacked — an explanation advanced by Hirt and 
others. Indeed, we may observe both the manifestations of 
chorea and rheumatism to a marked degree in certain severe 
cases of rheumatic fever, and the appearance of choreic symp- 
toms in such cases offers a grave prognosis, as they indicate a 
high degree of toxemia. 



DISEASES OF THE NERVOUS SYSTEM 355 

A neuropathic family history is found in a large percentage 
of cases, and epilepsy, insanity or alcoholism in the parents are 
undoubtedly potent predisposing causes of chorea. In this 
respect sex also plays an important role, as girls are far more 
frequently affected than males. Fright is an exciting cause in 
many cases. JSTo matter to which class the case may belong, 
this mental trauma acts as a precipitant of the symptoms. 

The largest number of cases is seen between the ages of seven 
to twelve ; before the fifth year it is quite rare, and after puberty 
it usually disappears spontaneously, although cases have been 
observed in adults. This must not, however, be confounded 
with Huntingdon's chorea, which is a hereditary disease devel- 
oping between the thirtieth and fortieth year, and presenting 
a most unfavorable prognosis. 

The pathology of chorea is still obscure. As the action of 
the toxins upon the cerebral hemispheres would in all probability 
excite only vascular and nutritional changes these are difficult 
to demonstrate. The frequency of unilateral disturbances early 
in the course of chorea, the cessation of symptoms during sleep, 
the blunting of the mental faculties and the occasional psychic 
disturbances observed, indicate that the gray matter of the 
cerebral cortex is pre-eminently affected. Organic changes in 
the structure of the brain may lead to the development of chorei- 
form movements, especially lesions following a cortical hemor- 
rhage. The term "post-hemiplegic chorea" has been applied to 
these cases, but the movements are, strictly speaking, athetoid 
in character, usually unilateral, not ceasing during sleep, and 
associated with rigidity and other evidences of organic disease. 

Symptoms. — The onset may be sudden or gradual. A severe 
fright may be followed within the course of a few hours or a 
day by evidences of extreme restlessness associated with twitch- 
ing of certain muscles and jerky movements of the extremities. 
In cases of more gradual onset the child becomes nervous and 
listless and shows signs of muscular weakness and awkwardness. 
It drops objects, writes indistinctly, tires readily and often 



356 DISEASES OF CHILDREN 

stumbles and falls down. When the coreiform movements are 
fully established they will be found to consist of rapid jerkings 
of single muscles associated with loss of power of coordination 
in attempting to perform voluntary movements. There is a 
delay in the carrying out of the voluntary movement and 
associated movements usually accompany the voluntary effort. 
Furthermore, the intended act is not successfully carried out 
and the child is unable to hold the arm or leg in the position 
attempted. The tongue and facial muscles are similarly affected 
and there is more or less impairment in the speech. Ludicrous 
grimaces may be executed, and the child is unable to remain 
seated quietly in one position for any length of time. The arms 
are thrown into continuous irregular action and the legs crossed 
or shifted from one place to another. Voluntary actions are 
executed with difficulty, being characterized by extreme awk- 
wardness and futility of purpose. Speech may become indistinct 
and muffled from involvement of the tongue and muscles con- 
trolling the larynx {laryngeal chorea) that it is difficult to 
understand the child. 

A more gradual development of the symptoms is seen in 
those cases resulting from overpressure at school, malnutrition 
following acute illness, or any other neuropathic cause. The 
child gives indications of gradually-increasing restlessness and 
awkwardness, the latter condition resulting from the hypotonia 
and inco-ordination. These phenomena may begin in one 
extremity or as a unilateral affection, the first symptom being 
paralytic weakness. The entire body soon becomes involved, 
and the apparent paralysis may disappear or simply share in 
the general muscular debility. These cases are described as 
paralytic chorea, monoparesis being the most common type. 
Church (Church and Peterson, Nervous and Mental Diseases) 
is of the opinion that many of these cases really belong to the 
neuritides or to a myelitis, or are combinations of these 
with chorea. 

The movements observed in the face are a twitching of the 



DISEASES OF THE NERVOUS SYSTEM 357 

eyelids and distortion of the mouth. The tongue exhibits 
marked choreic twitchings in the majority of cases, even in 
such where movements of the extremities are slight. Sachs 
{Nervous Diseases of Children) places especial diagnostic value 
on the movements of the tongue and associated facial action in 
propulsion of this organ, describing these combined movements 
as the "facies" or chorea. The tongue movements are slow and 
coarse, and propulsion of the tongue is attended with unneces- 
sarily wide opening of the mouth, raising of the eyelids and 
eyebrows, and catching of the tongue between the teeth through 
choreic movement of the masseters. 

The head may be turned from side to side and the shoulders 
alternately raised and lowered, the hands are alternately 
flexed and extended at the wrist, and the arms are thrown 
about in an irregular and jerky manner in severe cases. At- 
tempts to control these irregular movements or to perform 
voluntary acts only intensifies them, and the child may be- 
come unable to feed itself or execute other voluntary acts. 
When the child's hand is taken between the hands of the ex- 
aminer, the irregular muscular contractions are readily felt. 
Attempts to control the involuntary movements of the trunk 
and extremities usually intensifies them. The legs may be so 
affected by the muscular weakness and incoordination as to 
render it necessary to put the child to bed. Although sleep may 
be so disturbed as to exhaust the child to the extreme, and the 
great restlessness render it necessary to protect the child 
against falling out of bed, still, in the majority of cases, the 
movements abate on lying down and disappear entirely during 
sleep. The latter symptom is pathognomonic of chorea, serving 
to distinguish it from other motor disturbances. 

The temperature is normal in most cases; an elevation of 
several degrees should lead to a suspicion of rheumatism or 
endocarditis. The heart is affected in the majority of cases of 
chorea. The percentage of endocarditis reported by different 
writers varies greatly. Heubner found a murmur in 53 per 



358 DISEASES OF CHILDREN" 

cent of his cases, but this does not necessarily indicate that all 
had endocarditis. In hospital cases the percentage is highest, 
because the severer cases come to the hospital. Nevertheless, 
one sees cases of severe type in hospital practice in which there 
is no endocarditis. In my own cases about 23 per cent de- 
veloped endocarditis while 50 per cent gave a history of rheu- 
matism. Osier examined one hundred and forty cases two 
years after an attack of chorea and found evidence of organic 
heart disease in seventy-two of these patients. 

In older children mitral disease is closely associated with 
chorea. Beside organic manifestations, a cardiac neurosis is also 
encountered, inducing a group of symptoms which disappear 
with the disease. Both arythmia and a systolic murmur may be 
present, simulating valvular disease; but the murmur varies 
from day to day in intensity, is not transmitted, the pulmonary 
second sound is not accentuated, and hypertrophy does not take 
place. The condition has been called cardiac chorea, and is 
supposed to indicate irregular innervation of the papillary 
muscles. 

The mental state of the child is one of irritability, mental 
lethargy with deficient memory and power of concentration, 
and it may even assume a maniacal type of disturbance. Al- 
though true mental derangement is rare, it is not unusual to 
observe a highly exalted psychical state, especially with relapses 
or acute exacerbations in severe cases. The face becomes 
flushed; the eyes are brilliant and have a wild, staring ex- 
pression ; there may be alternate crying and laughing or simply 
crying out, and the general condition becomes greatly aggra- 
vated. With proper management such outbreaks are only of 
short duration, but they may become of serious import when 
associated with fever and progressive exhaustion, even termina- 
ting in coma and death. This constitutes the choreic status, 
which, however, is fortunately seldom encountered. 

The course of chorea is quite variable. Although usually 
described as a self-limiting disease, it is, nevertheless, one 



DISEASES OF THE NERVOUS SYSTEM 359 

which can be controlled to a marked degree by medication, 
whereby its course may be materially shortened and the symp- 
toms greatly moderated. On the other hand, although complete 
recovery is the rule, there are numerous instances in which num- 
erous relapses have been noted, or in which the child carries 
the evidences of chorea to adult life. The average duration 
can be placed at about from two to three months, always re- 
membering the possibility of relapses, especially in girls. In 
a series of dispensary cases reported by Bayley {Trans. Horn. 
Med. Soc. of Perm., 1896) the average duration from the time 
of onset was 19.4 weeks, and from the time of the beginning 
treatment it was 12.1 weeks. In private practice the course is 
usually shorter because treatment can be more satisfactorily 
carried out. 

Diagnosis. — The main source of error in the diagnosis of 
chorea will arise from confusing it with the motor disturbances 
of such conditions as post-he jniplegic chorea and athetosis, 
which are postplegic movements associated with paralysis of 
cerebral origin, and those of Freidreichs ataxia, multiple 
cerebrospinal sclerosis and hysteria. 

The history of the case, the facies of chorea, the character- 
istic movements and the association of rheumatic symptoms on 
the one hand and the absence of signs of an organic nervous 
affection on the other should render the differentiation easy. 
Tics or habit spasms are confined to one particular group of 
muscles, (eyelids, face, head, etc.) and usually result from 
some form of local or reflex irritation. They have nothing in 
common with chorea. 

Treatment. — As soon as evidences of chorea are observed 
the child should be taken from school and every effort made to 
eliminate from its life all excitement and mental and physical 
strain. The child must be treated with patience and kindness. 
Parents should be impressed with the fact that it is utterly im- 
possible for the child to control its movements, and that scold- 
ing or constantly calling the patient's attention to his condi- 



360 DISEASES OF CHILDREN 

tion will only aggravate the symptoms. Rest in bed is indicated 
in all grave cases of abrupt onset. All forms of physical exer- 
tion must be interdicted and fatigue strictly avoided. A 
change of scene and climate is often advantageous. In some 
instances it is best to take the child from its home surroundings 
and send it to a hospital or put it in the care of a trained nurse. 
During convalescence I believe judiciously carried out exer- 
cises are of great value. 

The diet is of importance. Bearing in mind the rheumatic 
element in these cases, fats, especially cod liver oil and butter, 
are of decided value. Meats should be cut down, but milk, 
eggs, cereals and vegetables may be taken liberally. 

Extreme restlessness, insomnia and mental excitement call 
for a warm bath at bedtime. Hot milk is also a valuable ad- 
juvant in these cases. 

The remedies from which I have obtained the best results 
are belladonna, causticum, hyoscyamus and agaricus. 

Where rheumatic symptoms are prominent, actea rac, rhus 
tox. and sulphur are frequently indicated and of value. In 
cases with pronounced psychic disturbances and extreme mus- 
cular activity, hyoscyamus is useful. 

Arsenicum, the chief remedy of the old school, administered 
in the form of Fowler's solution, and iron are useful when 
anemia and other conditions pointing to these remedies are 
prominent symptoms. 

Agaricus. — Spasmodic, jerky movements of the extremities 
and frequent nictitation of the eyelids (hyos.). Sensation of 
coldness and tingling in various parts; paralytic weakness of 
legs. The active principal of agaricus is not agaricin but mus- 
carin. Bayley speaks of the latter with praise. Personally 
my experience has been chiefly with agaricus in the second and 
third decimal dilution and it has acted well as a routine remedy 
in the milder, non-rheumatic cases. 

Bell. — Great mental excitement; delirium approaching to a 
maniacal condition ; the face is flushed and the eyes are brilliant 



DISEASES OF THE NERVOUS SYSTEM 361 

and staring; there is difficulty of speech, and a sensation of 
dryness and choking in the throat. 

Hyoscyamus should he given if bell, does not promptly re- 
lieve these symptoms, and if there is an incessant throwing 
about of the arms and a highly frightened behavior of the child. 

Caust. — Paralytic chorea with speech defect. The child 
stands in a limp, relaxed condition ; it is hardly able to walk or 
dress or feed itself; the voice sounds thick and unintelligible, 
and the tongue is protruded with difficulty. In such cases 
causticuon may be relied upon as of distinct clinical value. 

Cimicifuga. — Rheumatic pains in the small joints; endo- 
carditis ; after suppression of menses. 

Coccul. — Right-sided chorea; face puffed and bluish; hands 
and feet look as if frozen; paralytic symptoms. — (C. G. R.) 

Hyos. — Constant twitching of the eyelids; angular gyratory 
movements, with inco-ordination ; misses what he reaches for; 
silly expression of face, smiling at everything he hears ; chorea 
after debilitating fevers. 

Ignatia. — Highly nervous temperament; easily frightened; 
starts at the slightest noise, irritable temperament. Mild cases, 
developing after fright. 

Nux vom. — Sensation of numbness in the affected parts; 
frontal headache, constipation, indigestion, irritability and 
lassitude. 

Pulsatilla. — Chlorotic subjects; mild, tearful disposition; 
functional cardiac disturbances. Chorea developing at the time 
of puberty. 

Sulphur. — Protracted cases with frequent relapses; rheu- 
matic family history; after suppression of eruptions. Other 
constitutional remedies which may be called for upon purely 
diathetic indications are calc. carb. and phos., mercurius, 
phosphorus and silicea. The salicylates are often useful and 
will frequently accomplish more for a bad case requiring 
palliation than bromides. 



362 DISEASES OF CHIEDEEN 

SPASMUS NUTANS; HEAD-NODDING WITH NYSTAGMUS. 

The syndrome of rhythmic movements of the head associated 
with nystagmus is a peculiar condition occasionally encountered 
in rachitic and otherwise poorly nourished infants. Of late 
this phenomenon has attracted considerable attention among 
pediatrists, and a number of cases have been reported in the 
literature from time to time. 

Nystagmus may be the only symptom, or it may be the 
first symptom, other nervous manifestations, namely, head- 
nodding and laryngismus stridulus developing later, as oc- 
curred in one of my cases. Blepharospasm may also be present 
(Amberg), and associated movements in the extremities 
(Ausch) and temporary loss of consciousness (Hadden) have 
also been observed. As a rule, the movements cease during sleep. 

The majority of cases occur in infants under one year. The 
early signs of rickets are usually present. There is no pathol- 
ogic lesion, but most probably the symptoms are due to irri- 
tation or exhaustion of the nerve centres for the muscles gov- 
erning these movements. Henoch has pointed out that the 
nuclei of the oculo-motorius and the nerves governing the move- 
ments of the neck are adjacent, and that, therefore, they are read- 
ily irritated simultaneously. In many cases there is no doubt as 
to the exciting cause, namely, keeping the child in a dark room 
with the eyes exposed to the bright light of a window, analogous 
to the etiology of miner's nystagmus. All my cases have occurred 
in dispensary patients from the poor, crowded districts. 

The prognosis is favorable, as the symptoms depend partly 
upon the underlying malnutrition or spasmophilia which may 
be present in the case. The treatment is purely symptomatic 
and is to be conducted upon the lines as laid down in the dis- 
cussion of rickets. 



DISEASES OF THE NERVOUS SYSTEM 363 

NEUROPATHIC CONSTITUTION AND HYSTERIA. 

Many children show distinct evidence of a neuropathic con- 
stitution at an early age. The manifestations of such a 
constitution are an abnormal reaction both in intensity and 
duration, to physical and emotional stimuli. Certain forms 
of reflex irritation which a normal child may disregard are 
likely to produce marked symptoms while the emotional sphere 
of the child is intensely affected by its environment. 

The cause of such an unstable nervous system is mainly 
hereditary. As a rule the parents are neurotic or there is a 
family history showing a neuropathic taint. The child's en-. 
vironment is usually responsible for the development of the 
neuroses and psychoses which are liable to occur in these 
children. Certain nutritional disorders also disturb the normal 
balance of the nervous system and spasmophilia, hypertonia, 
the exudative diathesis and malnutrition with anemia are fre- 
quently found as an underlying condition. 

Symptoms. — The neuropathic infant is a poor sleeper, cries 
overmuch and is readily frightened. It is subject to frequent 
attacks of vomiting and diarrhea. Often outbursts of anger 
will occur during the first year of life and the infant demands 
the mother's entire time, day and night. As the infant grows 
older it becomes headstrong and self-willed. One of the greatest 
difficulties which these cases present is to make them eat the 
food selected for them; they will only eat certain things and 
will rather starve than eat what is set before them. Another 
difficulty is to make them sleep as much as they should. During 
sleep they often cry out, jerk and twitch or toss about constant- 
ly. They often suffer from night terrors or somnambulism. 
Many phobias are observed among these children; they are 
afraid to go to bed in the dark and they may have abnormal 
fears of certain animals or certain kinds of food. States of 
mental excitation and depression frequently alternate. They 
are abnormally imaginative and often given to the fabrication 



364 DISEASES OF CHILDREN 

of long stories of personal adventure (pseudologia phantastica). 
They become truants at school and they are often untruthful 
although appearing to be unusually bright and often possessing 
a certain personal charm. Some of the stigmata of hysteria are 
usually elicited in the careful examination of such children. 

HYSTERIA. 

Hysteria is a psychoneurosis described by Moebius as "A 
state in which ideas control the body and produce morbid 
changes in its functions." Almost every organic disease can 
be simulated by this peculiar nervous derangement, for which 
reason its recognition and proper understanding are of the 
highest clinical importance. Children are by no means exempt 
from hysteria, and sex bears no etiological relationship to the 
disorder. Although it may be encountered in early childhood, 
still it is rare before the tenth year, and most prevalent at the 
period of puberty and adolescence. Heredity plays an im- 
portant role, a neuropathic family history being present in 
most cases. In reviewing the child's life history it will be 
found that in most cases the manifestations of a neuropathic 
constitution were already present in early life. As exciting 
causes, emotional disturbances — especially fright, grief, jeal- 
ousy, and minor traumatisms in which the mental shock 
occurring at the time of the accident is entirely out of propor- 
tion to the injury sustained — are inseparably linked with 
hysteria. In the latter instance suggestion also enters into 
consideration, being one of the strongest influences in causing 
as well as in removing hysterical phenomena. Reflex irritations, 
such as tight and adherent foreskin or adherent hood of the 
clitoris, are mentioned as exciting causes. To these must also 
be added the baneful influence of improper training and dis- 
cipline, bad habits and various debilitating illnesses. 

Symptoms. — Hysteria in childhood differs from the hysteria 
of adults in the fact that the manifestations are simpler and 
more limited in their distribution, thus corresponding to the 



DISEASES OF THE NERVOUS SYSTEM 365 

immature mental development of the child. We rarely find the 
puzzling symptom complexes observed in the adult. Hysteria 
in childhood is usually monosymptomatic and when paralysis 
occurs it is more likely of a single extremity than hemiplegic 
or paraplegic as in adults. 

Stigmata. — The mental condition is characterized by dimin- 
ished will power, loss of memory and lack of determination, 
and indecision. Impressionability and irritability characterize 
the temperament. These subjects are very susceptible to 
suggestions, and the mood vacillates between sadness and 
gayety, uncontrollable paroxysms of alternate laughing and 
crying being a frequent occurrence. 

Disturbances of sensibility are encountered as complete or 
partial cutaneous anesthesia, or hyperesthesia in certain local- 
ities. It is usually found in parts which are paralyzed, a 
hemiplegia with anesthesia being strongly indicative of hysteria. 
Irregular islets of anesthesia are likewise characteristic of 
hysteria. The area of anesthesia does not correspond with the 
distribution of special nerve trunks or to the areas of sensation 
supplied by the different spinal segments, but seems to conform 
rather to the cortical representation of sensory areas. The 
mucous membranes may be anesthetic and the special senses 
become perverted or abolished, leading to disturbances of sight, 
hearing, etc., or sudden blindness or deafness. The throat may 
become anesthetic, so that we can irritate the fauces without 
producing gagging. Likewise, anesthesia of the nose, con- 
junctiva, larynx, etc., is to be encountered. The reflexes are 
not disturbed, as they are in organic lesions associated with 
anesthesia. 

The motor disturbances to be observed are a general retard- 
ation of voluntary movements and muscular weakness and inco- 
ordination. This is explained by the presence of anesthesia 
and loss of muscular sense and of the power of mental 
concentration. 

To the milder forms of spasmodic affections belong, notably, 



366 DISEASES OF CHILDREN 

globus hystericus ; hysterical cough, hiccough aud glottic spasm ; 
spasm confined to certain muscle groups, notably those of 
the neck. 

Accidents. — To the accidents of hysteria belong certain 
transitory disturbances manifesting themselves as convulsive 
seizures (grand attacks; hystero-epilepsy), or as motor and 
sensory disturbances of major degree, closely simulating a 
variety of organic diseases. 

Grand attacks belong to the rarer forms of hysteria in child- 
hood; but as they bear a superficial resemblance to epilepsy, 
they will be considered in full. The attack is preceded by 
depression of spirits and a sensory aura, most commonly the 
globus hystericus. This is described by the patient as the 
sensation of a ball rising into the throat and is due to spasmodic 
contraction of the pharynx and esophagus. A general tonic 
spasm, which persists for a few minutes, marks the first stage 
of the attack. The child lies stretched out, with the limbs 
extended and rigid, the fingers and toes being flexed. Slow, 
rigid movements of wider range executed by the arms, and 
flexion and extension of the feet, may be observed during this 
stage. The jaws are tightly closed, and respiration is slow 
and irregular or entirely suspended. The face assumes a bloated 
appearance, and the veins of the neck are prominent and 
swollen. 

The clonic stage is ushered in by short, jerky movements 
involving the face and extremities. These movements increase 
in severity, but do not assume the regular clonic type of 
epilepsy, being more irregular and of a struggling character. 
Respiration becomes interrupted and sobbing. Biting of the 
tongue is rare, as is also involuntary defecation and micturition. 
After the course of a few minutes the movements cease abrupt- 
ly, and a period of resolution or repose sets in — a condition 
simulating sleep. This may end the attack, or be succeeded by 
cataleptic manifestations, during which the patient becomes 
fixed in a variety of rigid postures. Extreme opisthotonos is 



DISEASES OF THE NERVOUS SYSTEM 367 

a common position observed in hysteria. A phase of large 
movements now follows, in which the subject may cry out in 
fear or rage and strike or bite at those about him. Peculiar 
sounds are sometimes uttered, resembling, for instance, the 
barking of a dog, and, when associated with the above symp- 
toms, constitute spurious hydrophobia. 

The period of passional attitudes observed in adults is very 
rarely seen in children. The period of delirium, in which the 
child sobs and pleads in a pitiful manner, or expresses various 
hallucinations, often terminates the attack, after consciousness 
is restored. 

Motor accidents occur as paralysis and contractures. They 
are usually of sudden onset, as the result of fright or injury; 
less commonly they develop gradually. Hysterical paralyses 
correspond in their general characteristics with those of central 
origin but there is a greater tendency to contractures and 
anesthesia and in cases of the leg there is a negative Babinski's 
sign. Monoplegias are more common than hemiplegia or 
paraplegia. Sometimes it is confined to a joint and simulates 
chronic arthritis. The paralyzed part is frequently anesthetic, 
and the anesthesia corresponds to the cortical distribution of 
sensation, not being confined to one or more nerve trunks, as 
in peripheral nerve and spinal affections. 

In hemiplegia the face escapes, with the exception of the eye- 
muscles, which are at times affected. Anesthesia is common, 
while in organic cerebral hemiplegia it is rare. Again, the 
contractures of hysteria partake more of the nature of spasmodic 
voluntary resistance, and atrophy never takes place excepting 
as a slight amount of wasting resulting from non-use. Loss 
of power is not absolute, and the degree of paralysis may vary 
from day to day. The gait also differs from that observed in 
cerebral palsies in that the leg is dragged along in a limp 
condition, not being swung out in a lateral direction, by which 
the foot is made to describe an arc. 

A characteristic form of hysterical paralysis observed in 



368 DISEASES OF CHILDEEN 

children is astasia abasia. In this condition the child can move 
its legs while lying down and reflexes are normal but he is 
unable to walk or stand. 

Contractures may exist independently or in association with 
paralysis and anesthesia. The extremities are most frequently 
affected. When the hands and feet are affected, the fingers 
and toes are flexed. With involvement of the larger joints there 
is extension, so that the arm and leg are held out straight. 
Contractures may occur in monoplegic, hemiplegic or paraplegic 
distribution. In deep sleep the rigidity usually disappears. 

Hysterical coxalgia is a most important subject presenting 
itself for consideration to the podiatrist. No doubt, the numer- 
ous cases of so-called reflex paralysis and coxalgia reported as 
having been cured by circumcision belong to this category. 
Apparently, every subjective and objective symptom of hip- 
joint disease has been mimicked by this neurosis, and nothing 
short of a careful examination under an anesthetic will serve 
to differentiate such a case from true hip-joint disease. This 
holds good for other joint affections in which fixation and pain 
without any objective signs are present. An X-ray examination 
will show the bones and joint surfaces in a normal condition. 
Under the influence of an anesthetic the rigidity of the joint 
disappears. 

Sensory Accidents. — A pseudo-meningitis is occasionally en- 
countered, and is distinguished from true meningitis by the 
history of the case, the absence of slowing or irregularity of 
the pulse and active pupils. In other respects it bears a close 
similarity to meningitis, presenting intense headache; vomiting; 
fever; vasomotor streaks (taches cerebrals), and rigidity of the 
neck and extremities. A lumbar puncture will serve to exclude 
meningitis. 

Spinal tenderness may be confined to the region of a few 
vertebrae and closely simulate Pott's disease; but if the 
patient's attention can be detracted momentarily a considerable 
amount of pressure will be borne without causing pain. 



DISEASES OF THE NERVOUS SYSTEM 369 

Visceral Accidents. — Disturbances in the respiratory tract 
show themselves as aphonia, usually developing suddenly after 
a fright, the voice being lost, but cough persisting; dyspnea, 
due to laryngeal or diaphragmatic spasm; tachypnea, sudden 
attacks of extremely rapid breathing, presenting alarming 
symptoms, without the evidence of physical signs to account 
for the same. 

In the digestive tract, vomiting, globus hystericus, eso- 
phageal spasm, anorexia and obstinate constipation are to be 
observed. 

Frequent urination of large quantities of pale, limpid urine 
or complete anuria, sometimes retention of urine, are the dis- 
turbances encountered in the urinary tract. 

The prognosis of hysteria is not unfavorable in children 
as they are readily influenced by suggestion, and, if the proper 
surroundings and intelligent treatment can be provided, re- 
covery is generally comparatively rapid. The accidental dis- 
turbances, as a rule, disappear spontaneously after a variable 
period of months or year, or they may come and go. The 
mental state can, however, seldom be improved beyond a certain 
limit, and the hysterical temperament will persist throughout 
life in the majority of cases. 

Sensory accidents are stubborn in their course, bringing con- 
siderable suffering to the patient and much anxiety to the 
friends and attendants. The spasmodic manifestations can 
usually be cured promptly if the patients can be taken from 
their parents and kept under intelligent supervision. 

In the diagnosis much importance is to be attached to a 
recognition of the stigmata of hysteria ; in other words, the 
hysterical temperament, in conjunction with the emotional 
origin of the ailment and the polymorphous and changeable 
character of the manifestations. Besides, the differential 
features serving to separate hysterical from organic diseases, 
as pointed out in the symptomatology, should serve in the 
differential diagnosis from organic affections. 
25 



370 DISEASES OF CHILDREN 

Treatment. — The general management of hysteria resolves 
itself into removing all exciting causes, isolation being the most 
effectual method for this purpose; attending to the removing 
of all sources of reflex irritations, such as phimosis, adenoids 
and errors of refraction, and building up the constitution by 
means of regular calisthenic exercises, a highly nutritious diet 
and a liberal amount of sleep. 

Suggestion is a most potent agent in restoring the patient's 
confidence and overcoming the various disturbances which 
have an imaginary origin. In managing cases of paralysis 
our main effort must be in the direction of promising the 
patient that the line of treatment employed will bring positive 
results. To emphasize this suggestion such adjuvants as 
massage and electricity are employed with benefit. This does 
not, however, apply to ill-managed cases of long standing, in 
which the surgeon's aid may have to be sought. 

The beneficial results following upon even the most trivial 
surgical measures resorted to in hysterical subjects is a note- 
worthy clinical fact, which often can be taken advantage of as 
a justifiable means of treatment. 

Medicinal treatment serves a two-fold purpose, namely, by 
augmenting the force of the suggestions and also by improving 
the patient's general condition. It is needless to mention the 
close relationship existing between neurasthenia and hysteria 
in children, and, therefore, remedies which will improve the 
nutrition of the nervous system cannot fail to influence the 
hysteria. Such remedies as picric acid, calcarea carb., silicea 
and phosphorus exert a potent influence in this direction. 

Remedies possessing notably hysterical symptoms are ignatia, 
hyoscyamus, aconite, asafoetida, moschus and valerian. The 
efficiency of drugs in such conditions as hysterical palsy and 
hystero-epilepsy is doubted by many. Arndt (Practice of Med- 
icine) expresses the opinion that a they are often helpful, 
especially in times of great emotional excitement." 

An unfortunate error often made in the care of hysterical 



DISEASES OF THE NEKVOUS SYSTEM 371 

subjects is to look upon them as simply imagining their troubles 
and, therefore, requiring no treatment. Nowhere more than 
in hysteria does it require firm yet kindly supervision and per- 
sistent and encouraging suggestion to lift the patient out of his 
imaginary fears and afflictions. With a hysterical child we 
have a campaign of education before us which must be con- 
tinued to adult life. 

PARALYTIC AFFECTIONS; CEREBRAL PALSIES. 

The cerebral palsies of childhood comprise a group of condi- 
tions which may be either of intra-uterine onset, or which are 
acquired during parturition or at a still later period. Cases of 
intra-uterine origin are usually developmental in character, and 
to this group belong porencephalia, agenesis corticalis and other 
defects, although evidences of hemorrhage and sclerotic changes, 
as a result of traumatism, fetal meningo-encephalitis and 
syphilis, have been observed in rare instances. 

In birth-palsies, hemorrhage is the primary lesion. It occurs 
frequently in protracted labors, and although forceps-pressure 
may directly induce a hemorrhage, still it does not play as im- 
portant a role as long-continued compression of the head in 
the pelvic straits or within the uterus. It has also been sup- 
posed that undue pressure upon the trunk during the extraction 
of a breech presentation may be the direct cause for the rupture 
of a bloodvessel in the brain. Cerebral hemorrhage is especially 
likely to occur in a precipitate labor of a large infant. The 
bleeding takes place from the capillaries and veinules of the 
pia mater or choroid plexus in most cases, more rarely from the 
longitudinal sinus and veins, and almost never from an artery. 
Venous congestion attending compression of the cord and 
asphyxia may give rise to a pial hemorrhage, but the weight of 
evidence is in favor of attributing the majority of cases of 
asphyxia neonatorum to hemorrhage. A new-born infant 
therefore, with pallid asphyxia should be looked upon as most 
likely an apoplectic one unless good reasons for some other 
cause are at hand. 



372 DISEASES OF CHILDREN 

Where the amount of blood-extravasation is not sufficient to 
cause death, it ultimately is absorbed or becomes organized 
with consequent sclerosis of adjacent areas of brain-substance 
and developmental retardation. The symptoms attending such a 
condition will naturally depend on the locality affected. 

The cerebral palsies encountered later in child-life are the 
result of either hemorrhage, embolism or thrombosis. A cere- 
bral abscess or tumor may likewise cause definite paralytic 
manifestations, but in their etiology and clinical course they 
differ distinctly from the foregoing conditions. Hemorrhage at 
this period of life is more frequently meningeal than cerebral. 
It may result from traumatism, arteritis, or from a sudden and 
severe venous congestion of the brain occurring during a con- 
vulsion or during a paroxysm of whooping-cough. 

Birth-palsies are usually bilateral, that is, diplegic or para- 
plegic, while the later palsies are most frequently hemiplegic. 
Sometimes hemiplegia attacks an infant in apparently perfect 
health, the symptoms coming on with fever, followed by con- 
vulsions and hemiparalysis. Strumpell first advanced the 
theory that these cases were inflammatory in character, due to 
an acute infection. The majority are examples of polioen- 
cephalitis, or the cerebral type of infantile paralysis. 

Abscess is most frequently secondary to suppurating otitis 
media. 

Sinus thrombosis results from extreme anemia in conjunc- 
tion with feeble heart's action occurring during exhausting 
illness, or from infection from the middle ear. In such cases 
thrombosis of one of the lateral sinuses, with its characteristic 
symptoms, results. Embolism is most frequently associated 
with endocarditis, only in rare instances originating from clots 
which have formed in the left auricle or elsewhere. 

Symptoms. — The lesions just enumerated may be productive 
of a variety of manifestations, for which reason we may en- 
counter either hemiplegia, diplegia, paraplegia or monoplegia 
in these cases. The last two are rare, especially monoplegia, 



DISEASES OF THE NERVOUS SYSTEM 373 

and paraplegia is frequently only apparent — a careful ex- 
amination also revealing evidences of paralysis in the arms 
together with mental deficiency. 

The mental condition is impaired and the head is usually 
small or irregular in form. Epilepsy develops in many of these 
cases, assuming the true degenerate type of the disease. 

Diplegic cases are congenital, or result from injuries sus- 
tained during parturition. As above stated, the lower extrem- 
ities are most markedly affected, and athetosis is a prominent 
symptom. Lack of mental development can be traced back to 
the earliest period of infancy and on account of the spasticity 
of the legs they do not learn to walk until very late. The 
rigidity in both arms and legs varies in degree; when pro- 
nounced it reminds one of the resistence encountered in bending 
a piece of lead, for which reason it has been described as "lead- 
pipe rigidity." Together with this there is a crossing of the 
lower extremities due to adductor spasm and a tendency to 
equino-varus. The gait is, therefore, extremely difficult or im- 
possible, and the hands are usually not well under control, 
being entirely helpless when athetosis is marked. A type of 
congenital diplegia resulting from defective development of 
the pyramidal tracts in the brain and cord, seen in under- 
developed or premature children, has been described by Little, 
of London (Little's Disease). Children afflicted with Little's 
disease are not deficient in mind, and the spastic condition 
usually improves with the development of the nervous system. 

Sachs (New York Medical J our., May, 1896) has reported a 
series of cases of congenital cerebral agenesis occuring as a 
family disease, in which amaurosis, progressive debility and a 
fatal termination are the clinical features. More or less 
diplegia, with spasticity, is usually present. A number of these 
cases is reported in the literature under the name of "Amaurotic 
Family Idiocy." 

The 'prognosis is unfavorable in all cases, but especially in 
the diplegic forms, in which little can be done aside from im- 



374 DISEASES OF CHILDREN 

proving the child's general state by means of massage and 
faradism, or by surgical measures when necessary. The proper 
training of such cases is, however, of the greatest importance, 
through which means both the mind and body may often be 
wonderfully improved. 

ACUTE POLIOMYELITIS, OR INFANTILE PARALYSIS. 

The term "Infantile Paralysis" expresses the popular con- 
ception of the specific acute infectious disease first systematic- 
ally studied and accurately described by Jacob von Heine in 
1840. It was long believed that this disease was a primary 
affection of the gray matter of the cord, whence the term 
"poliomyelitis." The study of old cases in which atrophy of 
the anterior horns of the spinal cord was found, was responsible 
for this view. Our present conception of poliomyelitis begins 
with the masterful study of the great epidemic in Sweden in 
1905 by Wickman. The pathological and clinical studies of 
Wickman showed conclusively that poliomyelitis is an acute 
infectious disease which is evidently spread by contact of 
healthy children with infected ones, and that one of the chief 
dangers of the rapid spread of an epidemic is the large number 
of abortive, or non-paralytic cases prevalent during an epidemic. 
His studies also demonstrated the fact that the disease is 
accompanied by a pathological reaction throughout the entire 
body, and that the lesions in the cord are but part of a general 
inflammatory reaction which sometimes involves the brain as 
well as the cord. 

Etiology. — Poliomyelitis occurs both endemically and epi- 
demically. In large communities we may expect to encounter 
sporadic cases at any season of the year. The striking charac- 
teristic of the disease, however, is its occurrence in epidemics; 
these usually reach their highest point of development during 
the hot summer months. Winter epidemics have occurred in 
Norway and Sweden. Whether insects are responsible for the 
spread of the virus has not been definitely determined. The 



DISEASES OF THE NERVOUS SYSTEM 375 

virus has been demonstrated in the secretions from the nose 
and throat of infected individuals and also in the stools. 
Sheppard {N. Y. State Jour, of Medicine, 1916, XVI, 442) has 
reported several instances of group infection which seem to 
prove conclusively that the disease may be transferred by human 
contact. 

Age is an important etiological factor. The great majority 
of cases occur in children from two to five years old. In some 
epidemics many adults have been attacked. Draper {Acute 
Poliomyelitis, Blakistons Son & Co., 1917) is of the impression 
that a certain type of child is especially susceptible to this 
infection. He calls attention to the large number of well- 
grown, plump, broad browed and broad and round faced children 
one sees attacked during an epidemic. 

The Organism. — Landsteiner and Popper in 1909 succeeded 
in transferring the disease to monkeys but were unable to 
propagate the infection. Shortly after their experiments were 
reported Flexner and Lewis succeeded in propagating the infec- 
tion indefinitely from monkey to monkey by means of intra- 
cerebral inoculations. In 1913 Flexner and Noguchi reported 
the successful cultivation of a filtrable virus with which they 
were able to reproduce the disease in monkeys. Recently a 
pleomorphic coccus has been isolated from the brain and cord 
after death from poliomyelitis by Mathers {Jour. Amer. Med. 
Ass., Sept. 30, 1916). This organism caused paralysis in rabbits 
and monkeys. Rosenow and others working independently 
report finding a similar streptococcus-like organism from the 
throat and tonsils as well as from the nervous system. "Whether 
this organism is a secondary invader or the actual cause of 
poliomyelitis and capable of existing in filterable and nonfilter- 
able forms has not been finally settled. 

Pathology. — Recent studies of fatal cases, and a close 
scrutiny of the symptoms of poliomyelitis, especially during 
the epidemics in which many atypical forms of the disease are 
encountered, show that poliomyelitis presents the character- 



376 DISEASES OF CHILDREN 

istics of a general infection, and that the meninges of the cord 
and sometimes of the brain are distinctly involved. It is now 
assumed that the infection gains access from the upper respir- 
atory tract, possibly through the nasal cavity, and is carried to 
the cerebrospinal nervous system by means of the lymphatics. 
The earliest changes observed are hyperemia and edema of 
the meninges with exudation into the arachnoid spaces (acute 
interstitial meningitis). This is most marked on the anterior 
surface of the cord and when the process extends into the cord, 
it does so along the blood vessels which enter the anterior 
fissure and supply the anterior horn of the cord. There is an 
associated infiltration of the meninges and medulla with 
mononuclear cells. This is most marked about the blood-vessels 
and may cut off the circulation from the nerve cells with 
resulting necrosis of the affected area. Sometimes hemorrhagic 
changes occur. 

Areas that have been affected by pressure only may regain 
their function after the hyperemia subsides and the cellular 
exudate is absorbed. Such areas, however, which have suffered 
from necrosis or extensive hemorrhage will undergo atrophy and 
present the typical appearance of the shrunken anterior horns 
mentioned in the older descriptions of the disease. 

Symptoms. — Poliomyelitis may present a diversity of clin- 
ical manifestations, since it not only varies widely in its severity, 
ranging from abortive, non-paralytic cases to fulminating, 
rapidly fatal cases, but also depending upon which region of 
the nervous system is mainly attacked. The following clinical 
types of poliomyelitis are recognized: 

(1) The Abortive Type. — Many cases of this type occur 
during epidemics and render control difficult. These cases are 
true instances of poliomyelitis, but lack the characteristic 
paralysis of the distinctly spinal type. Definite indications of 
meningeal involvement are, however, usually present. 

The attack may be ushered in by gastrointestinal symptoms, 
vomiting and diarrhea, or with coryza, cough, general malaise, 



DISEASES OF THE NERVOUS SYSTEM 377 

pains in the extremities. Moderate fever persisting for several 
days is present. Rigidity of the neck and Kernig's sign may 
be present, verifying the presence of meningeal involvement. 
Rigidity of the spine can also be elicited in many of these cases 
as well as tenderness of the muscles of the extremities and 
transient palsies. A lumbar puncture will verify the diagnosis 
when such suspicious symptoms are present. 

(2) The Spinal Type. — This represents the typical cases of 
poliomyelitis. The period of incubation is stated to be from 
five to ten days. A prodromal period is observed in most cases, 
the symptoms being referred to either the upper respiratory 
tract, the tonsils or the gastrointestinal tract. A characteristic 
feature of poliomyelitis is the fact that there is frequently an 
interval of several days of remission of symptoms between the 
occurrence of the prodromata and the initial symptoms of 
involvement of the spinal cord. Draper likens this arrangement 
of the two masses or humps of symptoms to the dromedary's 
back and speaks of the cases presenting this peculiarity as 
the "dromedary type." He is of the opinion that during an 
epidemic many children who are infected with poliomyelitis 
virus develop only the first group of symptoms because the virus 
gains entrance with difficulty to the central nervous system. 
The remission in paralytic cases indicates the time required 
for the virus to reach the cord. Cases of sudden onset may be 
regarded as examples of the malady in which the prodromal, 
or systemic stage has been overlooked or forgotten on account 
of its triviality. 

The onset is characterized by fever, rapid pulse, rapid res- 
pirations and restlessness. Vomiting is a common occurrence 
at this stage; convulsions are less common. Rapid pulse and 
sweating are very suggestive of poliomyelitis especially if there 
is associated the spinal rigidity so characteristic of the early 
stage of the disease. There may be an associated coryza, 
pharyngitis or diarrhea. 

The temperature is usually not high, averaging from 101° 



378 DISEASES OF CHILDREN 

to 103°. The pulse, however, is disproportionately rapid. Cases 
with involvement of the cervical portion of the cord have, in 
my experience, shown a slow pulse. 

The earliest symptoms referable to the nervous system are 
drowsiness and apathy associated with a characteristic nervous 
irritability. The child resents being touched or examined and 
wants to be left alone. As soon as the paralysis develops it 
becomes very fretful, complaining and cannot be made 
comfortable. 

Paralysis usually develops early; in the majority of cases 
the lower extremities will show signs of involvement on the 
first or second day after the fever has set in. It may not reach 
its maximum until the third or fourth day. Paralysis is rarely 
delayed beyond the sixth day. One of the gravest dangers 
of poliomyelitis lies in the possibility of the paralysis ascending 
to the centres controlling the respiratory muscles, with result- 
ing death from asphyxia. This sometimes occurs several days 
after the onset of the first signs of the leg paralysis. 

In the majority of instances the paralysis remains limited 
to the legs; sometimes the abdominal muscles and the muscles 
of the back are also involved. As the disease subsides it is 
generally found that one side is much more affected than the 
other. Involvement of the arms is rare. The astonishing 
feature of the disease is the rapidity with which the paralysis 
clears up during convalesence. Cases which presented a com- 
plete paraplegia during the height of the disease may be left 
with very little permanent paralysis. This is readily explained 
by the pathology of the affliction. From a study of the 
distribution of the lesions in 868 cases reported by Wickman 
it was found that paralysis was limited to one or both legs in 
353 instances and to a combination of arms and legs in 152 
instances. The arms were affected alone in only 75 cases while 
the trunk muscles were involved in conjunction with either the 
arms or legs in about 100 cases. 

The paralytic condition remains stationary for a period of 



DISEASES OF THE NERVOUS SYSTEM 379 

from two to three weeks. At the end of this time spontaneous 
improvement sets in and a gradual improvement in the para- 
lyzed muscles continues for several months. After that time 
improvement may continue but at a much slower rate and then 
only under appropriate treatment. Some improvement may 
still be anticipated as late as two years after the attack. 

The affected limbs present the flaccid type of paralysis 
resulting from involvement of the lower motor neurons with 
loss of the tendon reflexes. Muscles that are completely and 
permanently paralyzed undergo marked atrophy; sometimes 
the growth of the entire limb is retarded. As a rule, however, 
muscles are only partially paralyzed and the fibres which have 
escaped become hypertrophied and compensate for the defect. 
The extensors are more often involved than the flexors. There 
is early loss of faradic irritability in the completely paralyzed 
muscles and the reaction of degeneration can be elicited in them. 

(3) Bulbospinal Type. — This is a variety of the spinal type 
in which the cranial nerve centers in the medulla become 
involved. Usually it presents the terminal stage of the rapidly 
fatal ascending cases, simulating Landry's paralysis, in which 
the diaphragm and intercostal muscles are also involved. Some- 
times bulbar symptoms occur early, notably difficulty of 
deglutition and hoarseness. These cases are very serious but 
occasionally recovery takes place. Strabismus and facial 
paralysis are other frequent manifestations of this type and 
these cases also may recover; residual paralysis, however, 
usually remains. Bulbar symptoms may exist without any 
spinal involvement, although this is rare. 

(4) Cerebral Type. — This type was first described by Strum- 
pell, who recognized the clinical identity of polioencephalitis 
and poliomyelitis. In these cases the virus of the disease 
spends its effect upon the cortical motor areas of the brain 
instead of upon the gray matter of the cord and an upper motor 
neuron paralysis results. The resulting symptoms are a 
hemiplegia with spasticity, heightened reflexes and no atrophy. 



380 DISEASES OF CHILDREN 

The attack is usually ushered in with fever, vomiting, 
convulsions and delirium. Sometimes the symptoms closely 
simulate meningitis, which can only be differentiated by the 
lumbar puncture findings and the discovery of the associated 
hemiplegia. The prognosis is more grave than in the purely 
spinal type but it is not as fatal as other forms of meningitis. 

Diagnosis. — The diagnosis of poliomyelitis is readily made 
in the frank spinal type, the rapidly developing extensive 
paralysis of the legs with or without involvement of the arms 
and trunk muscles ; the paralysis being of the flaccid type with 
lost reflexes and promptly followed by muscular atrophy, 
stamps the case distinctly as one of infantile spinal paralysis. 
The atypical forms may present many diagnostic difficulties, 
however, especially the abortive types. This is particularly 
true in sporadic cases. The cerebral and meningeal types are 
frequently confused with meningitis and the differentiation 
can at times only be made by means of a lumbar puncture. 
Lethargic encephalitis in its early stages may also be confused 
with the meningeal type, especially since the lumbar puncture 
findings are similar in these two conditions. 

The characteristics of the cerebrospinal fluid in poliomye- 
litis are a clear fluid containing a high percentage of polynuclear 
cells in the first two or three days (preparalytic stage) of the 
disease. These are rapidly replaced by mononuclear cells. The 
average cell count is from 75 to 200. Another characteristic 
of the fluid is its power to reduce Fehling's solution; this is 
fairly constant and is not found in tuberculous meningitis. 
Globulin is markedly increased. Sometimes the fluid presents 
a characteristic yellowish discoloration. 

Treatment. — Absolute rest in bed during the acute inflam- 
matory stage is imperative. It is not wise to resort to massage 
or electrical treatment until pain and tenderness have disap- 
peared from the affected limbs and until the temperture has 
been normal for at least a week. The paralyzed limbs should 
at once be maintained in a proper position by means of pillows 



DISEASES OF THE NERVOUS SYSTEM 381 

and sand bags when necessary in order to prevent overstretch- 
ing of the paralyzed muscles and heat should be applied to 
keep the limbs warm. 

At the expiration of about three or four weeks active treat- 
ment with electricity and judicious massage may be begun. 
If the muscles do not respond to the faradic current, the gal- 
vanic should be employed. The object is to produce muscular 
contractions in order to improve the nutrition of the muscle 
and restore function as far as that is possible. Passive move- 
ments should be added to the treatment in order to overcome 
deformities. When once established, these will require surgical 
measures to correct them. The disability in a joint resulting 
from atrophy of one of the muscles either flexing or extending 
the same, is often satisfactorily corrected by a properly adjusted 
brace, which not only supports the joint but also prevents 
deformity. 

The remedies indicated in the early stages are aeon*, hell., 
bry., gels, and rhus tox. These are indicated by their influence 
over inflammatory processes in general and on account of their 
specific action upon the cerebrospinal nervous system and its 
investments. 

Belladonna corresponds both symptomatically and patho- 
logically to the stage of onset of the disease. The fever with 
hot skin, disproportionately rapid pulse, flushed face and 
bright glassy eyes, are strong indications for this remedy. 

When paralysis develops, gelsemium should be employed. 
This remedy has been extensively used in the homeopathic 
school with success and has been recommended recently by 
some old school writers. 

During convalescence mercurius may be given for the pur- 
pose of stimulating absorption of the exudate. If the affected 
limbs are painful and tender bryonia is preferable. 

For the residual paralysis, cwusticum is of value. In numer- 
ous instances I have seen improved tone in the paralyzed 
muscles follow its administration. 



382 DISEASES OF CHILDREN 

Serum therapy — The best results obtained from serum 
therapy have been with the use of human immune serum used 
both intra-spinally and intra-venously. Human serum, how- 
ever, is difficult to obtain and we therefore welcome a horse 
serum which promises to give definite curative results. 

Such a serum has recently been prepared by Rosenow by re- 
peated injections of the pleomorphic streptococcus isolated by 
him from cases of poliomyelitis but it is still too early to judge 
the results from the use of the same. 



PROGRESSIVE MUSCULAR ATROPHY. 

The Idiopathic Muscular Dystrophies bear a close outward 
resemblance to the late manifestations of anterior poliomyelitis. 
They have been divided into a variety of clinical types, but are 
all closely related both etiologically and pathologically. The 
main point of distinction between these myopathies and polio- 
myelities is their slow and progressive development, the sym- 
metrical distribution of the atrophic changes, and the hereditary 
factor in their etiology. 

The pathological changes observed in progressive muscular 
atrophy take place primarily in the muscles themselves, any 
changes found in the cord being looked upon as secondary. 
The muscle-fibres at first become hypertrophied, undergoing 
subsequent atrophy. The connective tissue is slightly increased. 

The following types are recognized: 

The Juvenile Type of Erb. — In this form the muscles of the 
arms and shoulders are mainly affected. 

The Facioscapulohumeral Type of Landouzy-Dejerine 
(Infantile Form of Duchenne), in which the face, together 
with the arms and shoulders, is affected. 

The Peroneal Type of Charcot and Marie, in which the 
peroneal muscles become atrophied. This may be followed by 
atrophic changes invading the legs, trunk and upper extremities, 
and there is evidence of cord-lesions associated with the atrophy, 



DISEASES OF THE NERVOUS SYSTEM 383 

showing itself as fibrillary twitching and reaction of de- 
generation. 

Pseudohypertrophic Paralysis is a disease of early childhood 
most frequently seen in boys, characterized by enlargement 
of the calves and buttocks, associated with atrophic changes. 
The muscles finally shrink, presenting the same condition as the 
other forms of atrophy. The characteristic symptoms produced 
are a waddling gait; difficulty of climbing up stairs and great 
awkwardness; enlargement of the legs and buttocks; lordosis; 
inability to rise from the ground without the aid of the hands. 
In order to attain the erect position the child supports the hands 
on the anterior surface of the thighs and gradually pushes 
himself upright. 

FAMILY ATAXIA. 

Family ataxia, also known as Friedreich's disease, occurs as 
a family disease, several or all of the children being attacked 
by a degenerative process of the posterior and lateral columns 
of the spinal cord. The cord lesion is a neurogliar sclerosis 
evidently an indication of a developmental defect. The first 
symptoms usually make their appearance shortly before puberty, 
a period at which the process of growth and nutrition are taxed 
to their utmost. When there are successive cases in a family 
they usually develop at a progressively increasing earlier period 
of life. An acute infectious disease may also hasten the devel- 
opment of symptoms, and for this reason the first symptoms 
may occur in early childhood following an acute illness. 

Hereditary cerebellar ataxia of Marie is characterized by a 
similar defective condition involving the cerebellum; but it 
develops after puberty, and is accompanied by pronounced 
choreiform movements, increased deep reflexes, and optic nerve 
atrophy, symptoms not found in spinal ataxia. 

Symptoms. — One of the earliest , symptoms noticed is an 
awkwardness in the legs, marking the beginning of the ataxia. 
Later the arms become involved. There is first unsteadiness in 
walking and standing, the child sways from side to side in 



384 DISEASES OF CHILDREN 

attempting to maintain its equilibrium. As the muscular sense 
is not lost, the condition depending entirely upon inco-ordina- 
tion, no increased difficulty in standing is noticed when the eyes 
are closed (absent Romberg sign). The ataxia is associated 
with gradually increasing loss of power. The knee-jerk is 
lost early in the disease (Westphal's sign). This distinguishes 
it from the cerebellar variety, in which there is also at times 
an ankle clonus. 

Disturbances of speech develop as inco-ordination becomes 
general. The speech is irregular and jerky, and lacks modula- 
tion and rhythm. 

Nystagmus may develop later in the disease, being especially 
noticed with lateral rotation of the eyes. The expression is 
one of apathy and indifference, although the intelligence is not 
impaired early, but it is retarded with the progress of the case, 
as is also the physical development. Shortening of the foot, 
with exaggerated plantar arch and retraction of the great toe 
(club-foot and hammer-toe), is a common deformity of family 
ataxia. Another deformity is dorso-lumbar scoliosis. These 
deformities may develop before ataxia becomes pronounced, 
and constitute early evidence of the disease. 

The course is that of a progressively-increasing and hopeless 
malady, but remissions or aggravations may take place. There 
is nothing in the disease itself to cause death, for which reason 
the person so afflicted may live to adult life. 

Isolated cases must be differentiated from cerebellar ataxia, 

chorea and multiple (insular) sclerosis. In the latter there is 

characteristically scanning speech, spastic gait and intention 

tremor. 

SYRINGOMYELIA. 

Syringomyelia is a disease of the spinal cord in which the 
spinal canal becomes pathologically enlarged as a result of the 
break down of a gliomatous infiltration. By the same process 
new canals of considerable length may be found within the gray 
matter of the cord. It is a rare affection in early childhood. 



DISEASES OF THE NEKVOUS SYSTEM 385 

The etiology is obscure and nothing definite is known, excepting 
that embryonal neurogliar tissue degenerates or becomes the 
seat of hemorrhage. 

The symptoms resulting from a central myelitis or from a 
hemorrhage into the cord — the latter, at times, occurring 
during parturition — cannot be distinguished from those belong- 
ing to glioma. 

Symptoms. — The disturbances of syringomelia may be 
divided into several groups. Involvement of the sensory path- 
way in the gray commissure and posterior horns and columns 
gives rise to loss of pain and heat perception, without, however, 
loss of the tactile sense. This anesthesia may be so complete 
and extensive as to render the patient insensible to almost any 
kind of pain and expose him to many dangers. 

Motor disturbances develop later than the sensory, and 
present paralysis of groups of muscles of a limb, usually becom- 
ing bilateral and accompanied by trophic changes. The re- 
action of degeneration is present. These symptoms indicate 
involvement of the anterior horns and pyramidal tracts. 

Vasomotor disturbances, cyanosis, coldness, cutaneous erup- 
tions and dermatographia may accompany the above process. 
Trophic changes, with resulting atrophy, fragility of bones, 
enlargement of the hands, and tendency to the development of 
whitlow and abscesses, are also to be noted. 

The course is progressive, and results fatally when bulbar 
crises set in. In the diagnosis, the idiopathic muscular dys- 
trophies, hysteria and multiple neuritis, are to be differ- 
entiated. The distinct features of syringomyelia are its gradual 
development and insidious onset, and the dissociation of touch 
and pain in conjunction with motor, trophic and vasomotor 
disturbances. 

MULTIPLE CEREBRO-SPINAL SCLEROSIS. 
Multiple of disseminated sclerosis, as the name implies, is 
a degenerative process affecting the brain and cord in an 
26 



386 DISEASES OF CHILDREN 

irregularly scattered sclerotic progress. The islets of sclerosis 
are found principally in the centrum ovale, crus, pons and 
medulla in the brain, and in the cord they are irregularly 
scattered, as a rule attacking the white matter more prominently 
than the gray. It is most common between the ages of twenty 
and thirty, but it may occur in children or even be congenital. 

The cause of multiple sclerosis is probably to be found in 
an infection, but, judging from the numerous and often mixed 
infections noted, it seems unlikely that we have to deal with 
a specific organism. — (Church). 

Symptoms. — Owing to the widely-distributed lesions of 
multiple sclerosis a variety of clinical manifestations are 
observed in this disease. The characteristic and most prom- 
inent features are: 

(a) Motor. — A coarse, jerky inco-ordination, especially in 
the arms, observed on attempts at voluntary movements. This 
intention tremor is associated with progressively increasing 
loss of power. The gait is spastic and is associated with de- 
ranged equilibrium. 

(b) Sensory disturbances are practically confined to the 
eye. Nystagmus is a frequent symptom, and optic neuritis 
and atrophy may develop. 

(c) Cerebral disturbances. — The speech defect, known as 
"scanning speech," in which there is an undue separation and 
accentuation of the syllables of words, and a state of indiffer- 
ence, loss of memory and dejection, are the prominent cerebral 
features of the disease. A predisposition to hysteria seems to 
exist, and it is not uncommon to find hysterical manifestations 
complicating multiple sclerosis. 

(d) The deep reflexes are exaggerated, as a rule, but there 
may be a loss of knee-jerk, and paralysis of cranial nerves in 
some cases. 

The clinical course of multiple sclerosis is quite irregular. 
It may begin gradually and increase in a progressive manner, 
or it may begin abruptly as an apoplectiform attack, or with 



DISEASES OF THE NERVOUS SYSTEM 387 

vertigo or visual disturbances. Remissions are not infrequent, 
and may lead to a belief that the disease has been checked ; but 
complete recovery must be very rare, although Church considers 
it possible. 

Diagnosis. — Multiple sclerosis is to be differentiated from 
infantile cerebral palsy, hysteria and family ataxia. In infan- 
tile cerebral palsy the history of traumatism during birth and 
the early appearance of diplegia, followed by mental retardation, 
rigidity and athetosis, will serve as a distinguishing feature. 
In hysteria the mental stigmata, the absence of nystagmus, and 
the presence of sensory disturbances and muscular rigidity, are 
of great significance, although both diseases may be associated 
in the same patient. In family ataxia there is inco-ordination 
and spasmodic muscular action; the knee-jerks are abolished, 
the muscles are flaccid, and the eyes are seldom affected, except 
by a slight degree of nystagmus, with lateral rotation of 
the eyes. 

The treatment of these cases is very unsatisfactory. Accord- 
ing to Arndt, arsenicvm is of especial value. Tarantula has 
also been recommended. Bartlett refers to the salts of gold, 
lead and mercury. 

MYATONIA CONGENITA. 

Myatonia congenita, or amyotonia, is a congenital affection 
in which the muscles of the extremities, especially those of the 
legs are abnormally flaccid and incapable of voluntary contrac- 
tion. The disease was first described by Oppenheim in 1900 
and is sometimes called Oppenheim's disease. The infant is 
limp and helpless and the legs are useless as in the case of a 
spinal paralysis. The knee-jerks are either absent or much 
diminished. The electrical reactions are diminished but there 
is no reaction of degeneration. The diaphragm escapes but 
the chest muscles are involved and the thorax presents a 
characteristic deformity simulating that found in rickets. As 
a rule some retardation in the child's mental development is 
also noted. 



388 DISEASES OF CHILDREN" 

The 'pathological process is confined to the affected muscles. 
These show a marked diminution in the size of the muscle 
fibres. The findings in the peripheral nerves and in the cord 
are negative. 

The diagnosis rests upon the congenital character of the 
affection and the absence of signs of a spinal lesion. The 
deformity of the chest is characteristic; rickets can be ruled 
out because this disease rarely develops before the end of the 
first year. Myatonia should not be confused with myotonia, 
or Thomsen's disease which is an hereditary affection character- 
ized by stiffness and rigidity of the voluntary muscles occurring 
during voluntary efforts. 

MULTIPLE NEURITIS. 

Inflammation of several nerves occurring coincidently or in 
quick succession occurs mainly from diphtheria during child- 
hood. Malaria, typhoid fever, scarlet fever, measles, influenza 
and acute rheumatism are responsible for some cases, but to 
a much less degree than the first mentioned infection. In 
marantic conditions and as a result of the cachexia of tuber- 
culosis it may be encountered. Toxic cases, notably those 
seen in adults resulting from alcohol, arsenic and mercury are 
rare in childhood. There is a class of idiopathic cases which 
are difficult to explain. They are usually described as rheu- 
matic and follow exposure to cold or from over-exertion. There 
is an epidemic type which is in all likelihood an atypical form 
of poliomyelitis. 

The lesions are a degenerative process in the axis-cylinders, 
not, however, affecting the nerve trunk uniformly and com- 
pletely. This is associated with hyperemia of the peri- and 
endoneurium. In some of the severe cases of diphtheritic 
paralysis degenerative lesions have been demonstrated in the 
cord and even in the brain in association with the neuritis. 

Symptoms. — The clinical course of diphtheritic paralysis 
has been described under diphtheria. In non-diphtheritic cases 



DISEASES OF THE NERVOUS SYSTEM 389 

there is first noticed a general weakness of the muscles, together 
with pain and tenderness along the affected nerves. Tingling 
and formication are also frequently complained of. The paral- 
ysis which results is usually of wide distribution, producing 
foot-drop and wrist-drop, inability to walk and spinal curvature. 
Partial anesthesia likewise develops, and considerable atrophy 
of the paralyzed muscles may set in. The knee-jerk is abolished, 
and if power of locomotion is not entirely lost the child shows 
marked ataxia in walking and standing. In the course of a few 
weeks improvement sets in, and after a time complete recovery 
is the rule, although some atrophy and loss of function may 
persist. Permanent disability is rare in children and the prog- 
nosis is good, as the etiological factors responsible for the 
unfavorable outcome in adults — such as alcohol — do not enter 
here. A fatal termination may take place in diphtheritic 
paralysis, or in other cases of rapid onset and wide distribution, 
in which the respiratory and cardiac innervation becomes 
involved. 

Diagnosis. — The gradual onset, usually during the period 
of convalescence from an infectious disease or after exposure 
to damp and cold (rheumatic cases); the symmetrical distribu- 
tion, and the accompanying sensory disturbances, will differen- 
tiate multiple neuritis from poliomyelitis anterior, as well as 
from the various ataxias. Its tendency to progressive improve- 
ment and recovery is another feature of diagnostic importance. 
The presence of pain is an important symptom, especially 
tenderness along the nerve trunks. 

Treatment. — The child should be kept in bed and put on a 
low protein diet. The affected limbs may be wrapped in cotton 
and heat should be applied for the relief of pain when this is 
present. Mild galvanization of the affected nerves and, as 
atrophy sets in, massage of the muscles are of great benefit. 
To overcome deformity in the extremities it may be necessary 
to resort to mechanical devices. 

Aconite. — Recent cases following exposure. Tingling and 



390 DISEASES OF CHILDREN 

formication in the affected parts is the chief indication. This 
and rhus tox. are the chief remedies in idiopathic neuritis. 

Arsen. — Malarial or cachectic cases; burning pains, general 
prostration. Marantic origin; cachexia. 

Argentum nitr. — Ataxic symptoms. 

Causticum is a most useful remedy for localized paralysis due 
to neuritis, or for the later changes of multiple neuritis. 

Gelsemium is useful in the early period of infectious cases, 
notably in diphtheritic paralysis. 

Rhus tox. is of great value in rheumatic cases. Traumatic 
cases call for arnica and hypericum, especially the latter. 

HEADACHE. 

A variety of conditions, notably anemia, chlorosis, lithemia, 
eye-strain, neurasthenia, hysteria, constipation and gastric 
derangements may give rise to headache. In inflammatory 
and organic brain affections it is a prominent symptom, and 
in the infectious fevers and in uremia it is quite constantly 
present. Syphilitic headache is rarely encountered in children. 
Headache is less common in children than in adults and is, 
as a rule, of more serious import especially when it is associated 
with fever or persistent in character. Under these conditions 
we should always consider the possibility of typhoid fever or 
meningitis and in the persistent, non-febrile type an intracranial 
condition should be suspected. 

Migraine is an essential headache, occurring paroxysmally 
and resulting from nervous discharges in the cortical sensory 
centres. The exciting causes may be any of the disturbances 
capable of producing headache, such as mental or physical 
fatigue, eye-strain, constipation, etc. The condition itself is 
usually hereditary, and is one of the manifestations of a neuro- 
pathic constitution, being, so to speak, a sensory epilepsy. 
In some instances a history of cyclic vomiting is obtained. 

The symptoms of migraine in childhood are the same as 
those observed in adults, with the exception that they are not 



DISEASES OF THE NEKVOUS SYSTEM 391 

quite so severe and usually of less frequent occurrence. 
Scintillating scotomata are often observed, being described as 
fiery flashes of figures before the eyes. The pain may be 
confined to one side of the head, and is accompanied by nausea 
and vomiting, the latter giving relief, as a rule, although 
indigestion has nothing to do with these attacks excepting that 
it may act as an exciting cause. Other disturbances — e.g., 
amblyopia; hemianopsia; aphasia; numbness and tingling in 
various parts of the body, followed by anesthesia, and possibly 
paralysis — may be observed during an attack. 

The diagnosis of migraine is based upon the paroxysmal 
nature of the attacks, the presence of nausea and vomiting 
without gastric derangement, and the accompanying sensory 
disturbances. Symptomatic headaches are recognized by their 
transitory nature and the presence of one of the etiological 
factors enumerated above. It is important both from the 
standpoint of prognosis and treatment to exclude intracranial 
disease in these cases and the patient should be observed over 
a sufficient length of time to determine the true nature of 
the case. 

Treatment. — Children subject to migraine should be care- 
fully dieted, especially avoiding the excessive eating of carbo- 
hydrate foods, particularly sugar. Kich foods must be excluded 
from the diet and such articles as chocolate, ice-cream, candy, 
cakes and nuts are especially harmful. Strict attention to the 
bowels is necessary although there may be no apparent constipa- 
tion. Errors of refraction must receive prompt attention. 

The most useful remedies in headache and migraine are 
iris, nux vomica and sanguinaria. Iris is indicated in "bilious" 
headaches accompanied by a blur before the eyes and vomiting 
of bile. Nux vomica is especially helpful in cases traceable to 
dietetic indiscretions with coated tongue and constipation. 
Sanguinaria, is indicated in the neurotic type of migraine and 
should be given between the attacks as well as during the same. 

Bell. — Congestive headache 5 throbbing of the carotids; 



392 DISEASES OF CHILDREN 

throbbing pains in the temples; face flushed. The pain is worse 
lying down, and is temporarily relieved from sitting np and by 
binding the head up tight. 

Cham. — Beginning with flickering and fiery zigzags before 
the eyes. Great irritability of temper. Neurotic cases. 

Gelsemium. — Purely neuralgic type of headache. 

Ignatia. — Hysterical headache; clavus hystericus; from 
emotional excitement or overpressure at school. Highly 
nervous temperaments. 

Iris. — The attack begins with dimness of vision and ter- 
minates with the vomiting of a yellowish, bitter, sour-smelling 
fluid. Usually right-sided. 

Nux vomica. — Headache traceable to errors in diet and 
neglect of the bowels. Nervous, excitable temperament, 
awakening in the morning with headache. 

Sanguinaria. — Pain beginning in occiput and spreading over 
the top of the head, settling over the right eye. Great sensitive- 
ness to light; flushes of heat and alternate chilliness. The 
attack ends in vomiting. Headache in chlorotic subjects. 
Subdued, tearful temperament; anorexia with coated tongue, 
no thirst. 



CHAPTER XV. 

DISEASES OF THE EAR, NOSE, AND THROAT. 
OTITIS. 

Inflammation of the middle ear is of common occurrence 
during infancy and childhood, although it is a condition that is 
frequently overlooked unless an ear discharge appears. Failure 
to make an early diagnosis in a case of purulent otitis media and 
neglect to drain the eardrum may result in the development of 
mastoiditis and permanent impairment of the hearing. Every 
case of otitis, however, does not present so serious a prognosis. 
As will be seen from a description of the affection, there is a 
mild catarrhal form complicating rhinopharyngitis or appar- 
ently occurring primarily and a serious suppurative variety 
which is usually a complication of one of the acute infectious 
diseases. Cases complicating scarlet fever are noted for their 
severe course. 

The external auditory canal is directed more forward in the 
infant than in the adult, for which reason it is at times neces- 
sary to draw the lobe of the ear downward and forward in 
order to insert the speculum instead of drawing the aurical 
upward and backward, as in adults. The Eustachian tube is 
wider, shorter and more horizontally placed than in the adult, 
and this anatomical feature, in conjunction with the prone 
position so constantly assumed by infants, offers the explana- 
tion why extension of an infection of the nose and throat 
travels so readily to the tympanum. The tympanic orifice is 
larger than the pharyngeal. Inflation of the middle ear is 
more easily accomplished than in adults. 

The membrana tympani, or drum head, is almost horizontally 
placed, gradually assuming the perpendicular position as the 
ear develops. It is thicker than in the adult and does not 
rupture so readily spontaneously. 



394 DISEASES OF CHILDREN 

The tympanic cavity is bounded superiorly by a thin plate 
of bone upon which the middle lobe of the brain rests. In the 
infant a suture, the petroso-squamosal, is found, allowing a 
vascular communication between the middle ear and the dura 
mater. For this reason meningeal irritation is so commonly 
observed in conjunction with otitis media. The close proximity 
of the inferior wall to the jugular fossa accounts for the tend- 
ency to phlebitis and thrombosis of the jugular vein as com- 
plications. 

The upper portion of the tympanic cavity containing the 
malleus and part of the incus is known as the attic. It com- 
municates with the mastoid antrum, and for this reason an 
accumulation of pus in the tympanum reaching to or confined 
to this point is usually followed by infection of the mastoid 
process. On acount of the underdeveloped state of the mastoid, 
however, involvement of the petrous bone and of the brain is 
more common than mastoiditis. 

The mucous membrane lining the tympanum is quite thin 
and vascular, presenting a reddish and swollen appearance in 
young infants. 

The mastoid process is but a small, undeveloped tuberosity at 
birth and contains, as a rule, only one cell, the antrum. It 
gradually develops by extending downwards and at the age of 
iive years reaches the adult type. The upper wall of the antrum 
is in close proximity to the dura mater, being separated there- 
from by only a thin layer of bone. 

The facial nerve passes along the upper portion of the tym- 
panic cavity and downward through the mastoid cells. For 
this reason it frequently becomes affected in middle ear and 
mastoid disease. 

Earache is the most prominent symptom of otitis, but it 
is possible for an inflammation of the middle ear to exist with- 
out pain. This sometimes occurs in marantic infants, in whom 
an ear discharge may be the first sign of trouble. Again, the 
pain may be vague and not definitely localized or be masked by 



DISEASES OF THE EAR, NOSE, AND THROAT 395 

cerebral irritation, but in these cases pressure at the tragus will 
usually elicit tenderness. 

Tenderness and redness (inflammatory blush) over the 
mastoid process indicates involvement of the mastoid cells and 
is an unfavorable symptom. 

Discharge. — In the acute forms of otitis media that lead 
to perforation of the membrana tympani the discharge is at 
first serous, later becoming muco-purulent. In the severe form, 
namely, that complicating scarlet fever, it is usually purulent 
from the beginning; the ordinary catarrhal variety, however, 
may assume a purulent character if its course becomes 
protracted. 

Tuberculosis. — In the tuberculous variety of otitis the 
mucous membrane of the tympanic cavity is pale and the dis- 
charge is watery or a thin pus, in which the tubercle bacillus 
may be demonstrated. Multiple perforation of the membrana 
tympani is characteristic of tuberculous otitis. 

Influenza. — Otitis media is a frequent complication of 
influenza and during epidemics of this disease many cases of 
otitis are usually encountered. In this variety the discharge is 
at first sero-sanguinolent, later becoming sticky. There is al- 
ways more or less blood, on account of the great congestion of 
the mucous membrane of the tympanum and of the drum head. 

ACUTE CATARRHAL AND ACUTE PURULENT OTITIS MEDIA. 

The two varieties will be considered under the same heading, 
as it is impossible to draw a sharp line of distinction between 
them. The catarrhal variety is by far the commoner in 
infants, while in older children the purulent variety pre- 
dominates. The explanation of this lies in the fact that 
catarrhal otitis usually develops secondarily to an acute naso- 
pharyngitis, while the purulent variety develops in the course 
of one of the infectious diseases, notably, scarlet fever and 
measles, and less frequently in typhoid fever, pneumonia and 
diphtheria. Influenza is a common cause of the more severe 



396 DISEASES OF CHILDREN 

catarrhal cases. The micro-organisms most commonly found 
in the discharge are the pneumoeoccus and the streptococcus; 
the latter is responsible for the damage done to the middle 
ear and adjacent structure in scarlatinal otitis and the other 
grave symptoms of suppurative otitis. Adenoids are the most 
prominent predisposing cause. 

Symptoms. — In infants otitis is usually preceded by a 
nasopharyngitis; as the ear becomes involved there is an 
increase of fever and earache sets in. Although the child fre- 
quently gives evidence of the seat of the pain by putting the 
hand to the side of the head and by crying when the affected 
ear is touched, still there are a great many cases in which ear- 
ache is not suspected until the membrana tympani has ruptured 
and a discharge makes its appearance. This is especially the 
case when otitis complicates an acute illness, such as pneumonia, 
for example. In these cases there will be a persistence of fever 
that cannot be accounted for and the child will cry incessantly 
for no known reason. In the course of a day or two the appear- 
ance of the ear discharge clears up the mystery. Sudden ex- 
acerbation of fever in any acute illness not explained by other 
complications and persistent crying should always lead to an 
examination of the ears. 

In older children the disease is ushered in with excruciating 
pain and high elevation of temperature. Pain begins in the 
ear, but radiates over the entire side of the head. As a rule, 
it is promptly relieved when perforation of the membrana tym- 
pani takes place. 

Often the symptoms closely resemble meningitis ; the disease 
is ushered in by convulsions and vomiting, and marked cerebral 
irritation is present on account of the close connection between 
the middle ear and the dura mater. These symptoms, however, 
disappear as soon as the middle ear is evacuated. 

Early in the disease the drum head in the region of Shrap- 
nell's membrane is congested. There is also hyperemia ex- 
tending along the posterior border of the handle of the malleus ; 



DISEASES OF THE EAR, NOSE, AND THROAT 397 

the drumhead loses its lustre and assumes a deep pink color 
varying with the intensity of the inflammation. The external 
auditory canal also becomes deeply congested. 

At first the drum head is somewhat depressed, but as the exu- 
date fills the tympanic cavity it bulges, especially in its posterior 
half. When perforation occurs it most frequently takes place 
in the lower anterior or posterior quadrant of the membrane. 
Spontaneous perforation is less apt to drain the tympanum as 
thoroughly as an artificial puncture, nor does it heal as well. 

When the pain continues after perforation, we should sus- 
pect involvement of the periosteum or of the mastoid cells. 

The complications of otitis media are mastoiditis; facial 
paralysis; meningitis; cerebral abscess; septicemia; thromr 
bosis of the lateral or other sinuses; facial erysipelas and 
eczema aurium. 

Prognosis. — This is admirably summed up by Palen and 
Clay {The Practitioner s Otology, The John C. Winston Co., 
1921) as follows: "On account of the complications which 
may occur during the course of this disease, a guarded prog- 
nosis is at all times advisable. The prognosis depends, to a 
large extent, upon the causal factor and upon the method of 
treatment. Cases orginating from scarlet fever, measles or 
diphtheria, are especially apt to be virulent and to become 
chronic. The otitis occurring with certain epidemics of influ- 
enza is also frequently of a very virulent character, while 
those occurring from simple colds, exposure and nasal obstruc- 
tions are less severe in character and less destructive. The 
prognosis, in all cases, will depend also upon the type of infect- 
ing organism and the resistance of the patient. A virulent 
organism in a patient with good resistance may produce a mild 
type of otitis media, while in a patient with markedly lessened 
resistance it will exhibit its virulency to a marked degree. 
Among the most virulent aural bacteria are the different types 
of streptococci and the pneumococci. The prognosis, where 
these are present, is less favorable, as regards duration of the 



398 DISEASES OF CHILDREN 

condition and tendency to complications, than it is if the 
staphylococci are the causal bacteria." 

Diagnosis. — Earache should always be suspected when an 
infant cries continuously or when the fever suddenly rises 
during the course of an acute illness without assignable cause. 
When enlarged tonsils and adenoids are present the probability 
of earache should always be born in mind. Inspection of the 
ear drum will give positive evidence of the disease. 

Treatment. — Absolute rest in bed should be enforced and 
much relief of suffering may be obtained by instilling hot water 
into the external auditory meatus, or better, by the instillation 
of a one per cent solution of carbolic acid in glycerin. This 
procedure is not only useful in relieving the pain, but will at 
times abort the attack by osmotic action through the membrana 
tympani, and in any case it will render the canal aseptic in 
anticipation of perforation, natural or artificial (C. M. 
Thomas). The use of oily preparations in the ear should be 
discouraged. 

The most important remedies are aconite, belladonna and 
Pulsatilla Their use is not limited to the homeopathic school. 
Thus, Bacon (Manual of Otology) says: "Aconite in drop doses 
is a most valuable remedy when there is fever and especially 
in cases due to cold. Tincture of pulsatilla, likewise given 
in drop doses, is indicated also in cases in which there is profuse 
discharge from the nares or naso-pharynx, and may be admin- 
istered alternately with aconite/' The nose and throat should 
also receive attention. Unless the pain is promptly relieved 
by these measures and when the fever and appearance of the 
membrane indicate an accumulation in the middle ear, incision 
of the drumhead should be performed. Palen and Clay (loco 
cit.) express themselves as follows on this subject: "While 
many pages have been written upon the local treatment of acute 
otitis media and especially upon ways and means to lessen or 
control the pain occurring in these cases, we believe that the 
only treatment for the relief of pain, which occurs before the 



DISEASES OF THE EAR, NOSE, AND THROAT 399 

drum has perforated, is the establishment of good drainage 
by means of an early and free incision of the drum." 

A successful paracentesis is a free incision of the membrane 
and not merely a puncture. It should be done under a general 
anesthetic. The technique is as follows: the patient having 
been anesthetized and the external auditory canal thoroughly 
cleansed with a hot 1-5000 bichloride of mercury solution, the 
drumhead is inspected with the aid of a speculum and head 
mirror in order to determine the site of bulging if this be 
demonstrable. The incision is made with a narrow bistoury or 
tenotome. Ordinarily the line of incision extends from just 
behind the stapes to the lower border of the drumhead, closely 
hugging the bony structure of the posterior canal. In grave 
cases, with bulging of the drumhead in its posterior and upper 
quadrant, together with indications of mastoiditis, the incision 
should be carried well up the posterior fold and into the attic. 
At the same time the knife should be brought out along the 
upper posterior wall of the external auditory canal to relieve 
all tension. The canal is then lightly packed with sterile gauze 
and after the acute symtoms have subsided irrigation with a 
saturated solution of boric acid may be resorted to several 
times daily. Inflation, cautiously employed, when the perfora- 
tion is large, helps to remove the secretion from the tympanum. 

Remedies. — In the acute stage, aconite and pulsatilla are 
most commonly indicated (see above). Belladonna is the remedy 
when cerebral symptoms are prominent. Capsicum is highly 
recommended for the early stages of mastoid involvement. 

During the period of discharge, pulsatilla and calcarea iodid. 
are most useful. Hydrastis is particularly indicated in influ- 
enzal cases, when the discharge is sticky and tenacious. When 
the discharge excoriates we should think of mercurius and in 
involvement of the bone silica is the most useful remedy. 



400 DISEASES OF CHILDREN 

ACUTE TONSILLITIS. 

Acute inflammation of the tonsils may be either superficial, 
or catarrhal; follicular, or cyptic; and parenchymatous. 
Anatomically the tonsils consist of an aggregation of lym- 
phoid tissue embedded in connective tissue and covered by a 
mucous membrane from whose surface numerous mucous glands 
dip into its parenchyma. These glands form so-called crypts, 
or follicles, and they play an important role in the diseases of 
the tonsil. 

Clinically the tonsil is an important port of entrance of the 
organisms of many of the infectious diseases. Diphtheria and 
scarlet fever primarily attack the tonsils, and rheumatic fever 
can frequently be traced to a tonsillar infection. 

Acute Superficial Tonsillitis. — As the name implies, acute 
superficial tonsillitis involves only the mucous membrane cover- 
ing the tonsil. The process may also spread to contiguous 
structures, and it either undergoes prompt resolution or in the 
case of secondary infection is followed by superficial necrosis 
of the epithelium, or suppuration of the connective tissue takes 
place, resulting in peritonsillar abscess. 

It is a common accompaniment of many of the infectious dis- 
eases notably measles and scarlet fever. In primary cases the 
usual etiological factor is "taking cold," and by many it is 
believed that the "rheumatic diathesis" offers especial predis- 
position to these attacks. 

Symptoms. — In primary cases there is malaise and slight 
chilliness, together with dryness of the throat and some pain 
on swallowing. The tonsils appear bright red, swollen, and 
their surface presents a somewhat edematous appearance. It 
is seldom that the process ends here, however, the crypts usually 
becoming occluded and filled with fibrin, leucocytes and epi- 
thelial debris, which constitutes acute follicular tonsillitis. 

Associated symptoms are fever; headache and malaise; stiff- 
ness of the neck, even torticollis and earache. 



DISEASES OF THE EAR, NOSE, AND THROAT 401 

ACUTE FOLLICULAR TONSILLITIS. 

Acute follicular, or cryptic tonsillitis, is an acute infection 
of the tonsils. The germs usually found are the streptococcus, 
staphylococcus, and pneumococcus. As a rule the infection is 
limited to the crypts of the tonsils whence the name of the dis- 
ease. In some instances the process extends beyond the mouths 
of the crypts and spreads over the surface of the tonsils pro- 
ducing a clinical condition simulating diphtheria. These cases 
are usually due to a streptococcus infection and may occur as 
epidemics of "septic sore-throat" or as a complication of scarlet- 
fever (pseudo diphtheria). 

Symptoms. — The attack begins with malaise and chilly 
sensations, usually along the spine, followed by fever and 
aching throughout the body. There is dryness of the throat 
and some pain on swallowing, but frequently the child does 
not refer to its throat until the tonsils are greatly swollen. 
The sudden onset of a chill and high fever without the com- 
plaint of sore throat may prove very misleading unless a routine 
examination of the throat in all acute illnesses is made. 

Fever persists for about three days, together with an incre- 
ment in the severity of the symptoms, ranging between 100° 
F. to 105° F. By this time the inflammation of the tonsils has 
reached its climax and they present a characteristic appearance. 
They are deeply congested, uniformly swollen and their surface 
is studded with yellowish- white, punctate spots appearing at 
the mouths of the crypts. When the exudation is abundant 
it spreads over the surface of the tonsils and may give rise to 
the appearance of a membrane. This is, however, readily wiped 
off. Again, necrosis of the epithelium around the mouths of 
the crypts may occur, the spots assuming an irregular outline, 
like a diphtheritic membrane, and these spots may coalesce; 
but the deposit is only superficial and is readily wiped off, 
distinguishing it from diphtheria. 
27 



402 DISEASES OF CHILDREN 

The lymphatic glands of the neck may become enlarged 
and tender, but never to the extent found in diphtheria. 

Associated symptoms are painful deglutition; lancinating 
pains extending into the ears; headache and prostration. 

The tongue is coated and slimy; the breath is offensive, and 
there is anorexia and constipation. 

The fever subsides on about the third day; the tonsillar 
swelling abates at the same time, and convalescence is estab- 
lished in the course of a few days. 

Diagnosis. — The most important condition from which 
follicular tonsillitis is to be distinguished is diphtheria. In a 
typical case this is comparatively easy, but in the class of 
cases described as pseudo-diphtheria many difficulties are 
encountered. 

The characteristic points to be remembered in the diagnosis 
of follicular tonsillitis are: the punctate spots of soft, unor- 
ganized exudation confined to the tonsillar crypts; the uniform 
inflammation and swelling of the tonsils; the bilateral character 
of the affection; the high fever and pain and the absence of 
profound toxemia; and, lastly, the absence of marked enlarge- 
ment of the lymphatics of the neck. In all doubtful cases, 
however, a bacteriological examination of the exudate should 
be made. 

Treatment. — The child should be put to bed and isolation 
of the patient enforced. When there is much pain and swelling 
of the tonsils an ice collar will give relief. The throat may 
be sprayed several times daily with a mild antiseptic, such as 
boric acid or hydrogen peroxid. Local applications of a ten 
per cent solution of argyrol may also be employed. 

The most important remedies are: belladonna, mercurius 
iod. rubr. and apis. 

Belladonna is indicated in the early stage when there is 
dryness and redness of the throat with pain on swallowing; 
throbbing headache; photophobia; high fever and flushed face. 
It is more frequently indicated in tonsillitis in children than 
in adults. 



DISEASES OF THE EAR, NOSE, AND THROAT 403 

Apis is indicated when edematous swelling of the mucous 
membrane is the leading feature in the case. There are sharp, 
sticking pains on swallowing. 

Mercurius iod. rubr. is the most useful remedy in the fully 
developed stage of the affection. 

VINCENT'S ANGINA. 

Vincent's Angina, or ulcero-membranous tonsillitis,, is an 
affection bearing a superficial resemblance to diphtheria but 
presenting none of the toxic manifestations of this disease. 
In ulcero-membranous tonsillitis the tonsil becomes covered 
with a dirty-yellowish exudate ; this is often confined to a single 
tonsil. When the exudate is wiped away, especially if done 
roughly, a bleeding surface may remain. The lymphatics at 
the angle of the jaw on the affected side are swollen. Thus far 
there is a strong resemblance to diphtheria, even to offensive 
breath, but constitutional symptoms are slight or wanting 
and a bacteriological examination reveals instead of the 
Klebs-Loeffier bacillus the fusiform bacillus of Vincent and its 
accompanying spirillum. Ulcerative stomatitis may be an 
associated condition. 

The treatment is the same as for other forms of tonsillitis. 
Locally, hydrogen dioxid, preferably as a spray, is the most 
useful cleansing agent. It may be followed by the application 
of iodine and glycerine (one part tincture of iodine to five parts 
glycerine). 

Merc. iod. rubr. — This is the most useful remedy in cases 
resembling diphtheria where there is superficial ulceration of 
the tonsils; fibrinous exudation and enlargement ,of the cer- 
vical lymphatics. 

ACUTE PARENCHYMATOUS TONSILLITIS; PERITONSILLAR 

ABSCESS. 

Acute parenchymatous tonsillitis, commonly called "quinsy," 
results from an infection of the peritonsillar tissue. Suppura- 



404 DISEASES OF CHILDREN 

tion as a rule sets in, taking place in the peritonsillar connective 
tissue and terminating in the formation of an abscess which may 
rupture intx> the pharynx either anteriorly or posteriorly, 
following the line of least resistance. It is a disease common 
in later childhood and in adolescents. 

Symptoms. — The onset is similar to that of other forms of 
tonsillitis, with the exception that the inflammation is one- 
sided and attended with more pain and swelling. The pain at 
first is lancinating; later it becomes throbbing in character. 
There is a constant desire to swallow, which adds greatly to the 
discomfort of the patient. Fever and malaise are usually not so 
marked as in follicular tonsillitis. 

On inspection, the throat presents a swollen, edematous 
appearance and a tumefaction arising from the tonsillar region 
is seen projecting toward the median line. The tonsils and 
pharynx are covered with a grayish, viscid mucus which gives 
the appearance of a thin pseudo-membrane, but by spraying 
the throat it can be completely removed. The tonsil itself is 
not the seat of the chief swelling, but it is carried into the 
median line by the surrounding tumefied structures. The 
opposite side may become affected later on, but the disease is 
rarely bilateral. Inspection is difficult on account of the stiff- 
ness of the jaw that is associated. Fluctuation may be elicited, 
but it is not always easy to determine on account of the boggy, 
edematous condition of the tissues. 

The duration is from a few days to a week or longer. 
Resolution may set in, or spontaneous evacuation take place 
after four or fi.Ye days with prompt relief of the symptoms. 

Treatment. — If suppuration cannot be aborted by the use 
of the ice-bag and the indicated remedy, the abscess should 
be evacuated as soon as pus is suspected and an antiseptic 
gargle freely used. The incision is made with a sharp pointed 
bistoury whose cutting edge has been wrapped in cotton, 
exposing only the point for a distance of about a quarter of an 
inch. The point is inserted to its full length into the substance 



DISEASES OE THE EAR, NOSE, AND THROAT 405 

of the half arch just above the tonsil and a quarter of an inch 
from its free border. Peritonsillar abscess can often be most 
satisfactorily evacuated by passing a bent probe outward and 
upward posteriorly to the anterior half and into the supra 
tonsillar fossa (Thomas). The patient should then gargle with 
a warm 2 per cent boric acid solution, or diluted hydrogen 
dioxid so long as pus is present. 

Remedies. — Belladonna in the early stage; later as soon 
as pus begins to form, mercurius vivus; and hepar sulph. 

Apis may become indicated from a predominance or edema. 

Capsicum. — Serous infiltration of the faucial tissues; boggy, 
not edematous, in apearance; left side worse; pain burning, 
stinging. When tongue is heavily coated white, uvula edema- 
tous, especially with a dusky infiltration of the left pillars 
and some sAvelling of the lymphatic glands, caps., in the 3x 
or 6x, will usually releive inside of twenty-four hours (Ivins). 

Phytolacca. — Chills and fever alternate; prostration; pain 
running to ears on deglutition; affected parts dark-purple, 
almost blue; rheumatic subjects; uvula enlarged and edematous. 

Silicea. — Protracted cases. Suppuration continues after 
evacuation of pus has taken place {cole, sulph.). 



HYPERTROPHY OF THE TONSILS. 

There are two varieties of hypertrophy of the tonsils; in 
the one the increase in structure is mainly glandular, while 
in the other it is interstitial. The first variety is known as 
the soft, glandular type; the other as the hard, fibroid, or 
lobulated tonsil. An enlarged tonsil is not necessarily an 
hypertrophied one, as enlargement may result from vascular 
engorgement and does not necessarily indicate cell proliferation. 
Again, in children the tonsils are normally large, and because 
they extend beyond the pillars of the fauces, it does not 
necessarily follow that they are hypertrophied (Kyle). At 
the time of the eruption of the last molar teeth a physiological 



406 DISEASES OF CHILDREN 

enlargement of the tonsils occurs which may subside as the 
child grows older. 

The cause of the various enlargements is both constitutional 
and acquired. The scrofulous diathesis and the status lym- 
phaticus are constitutional states predisposing to hyperplasia 
of all lymphoid structures. Recurring attacks of tonsillitis 
lead to hypertrophy of the tonsils and all infectious diseases 
which attack the tonsils aggravate the same. In many cases 
no etiological factor can be discovered. Often enlarged tonsils 
and adenoids appear as a family trait. 

Symptoms. — Subjective symptoms depend largely upon the 
size of the tonsils. They may be so large as to cause consider- 
able interference with normal respiration by filling up the 
pharyngeal space, and under these circumstances the voice is 
also affected, acquiring a nasal twang. Many of the symptoms 
resulting from adenoid vegetations are also caused by enlarged 
tonsils. Interference with the appetite is a common disturbance 
and when the tonsils are infected the manifestations of a focal 
infection can usually be elicited. An infected tonsil is not neces- 
sarily an enlarged tonsil. It may be partly submerged in the 
tonsillar fossa or covered by the plica triangularis and appear 
as a small tonsil when in reality it is hypertrophic and diseased. 
(Palen and Clay.) 

In the soft variety the tonsil is uniformly enlarged, while in 
the fibrous variety it is tabulated; the crypts are abnormally 
large, and its consistency is hard and unyielding. 

Treatment. — Unless the tonsils are sufficiently enlarged to 
interfere with the child's health, or to affect the voice, they will 
require no further treatment than mild local measures and a 
remedy prescribed upon a constitutional basis. It is the 
simple, hypertrophic variety of enlarged tonsil without con- 
nective tissue proliferation that so promptly improves under 
appropriate treatment and undergoes physiological atrophy in 
later life. The fibroid variety, however, is rarely improved by 
treatment of any kind, and if it be large enough to cause symp- 



DISEASES OF THE EAR, NOSE, AND THROAT 407 

toms it should be enucleated. This also holds good in the case 
of infected tonsils whether they be large or small. If there is 
a history of recurring attacks of tonsillitis and if the sub- 
tonsillar lymphnodes are enlarged the tonsils are in all prob- 
ability infected. Should rheumatic symptoms or other evidences 
of focal infection be present the tonsils should be removed. 

In simple hypertrophy of the tonsils calcarea phos. has 
proven clinically useful. 



RETROPHARYNGEAL ABSCESS. 

Betro-pharyngeal abscess results from an acute infection of 
the lymphatic glands and vessels of the pharyngeal space. A 
septic variety, occurring as a complication of scarlet fever and 
measles, is sometimes encountered, but it is much rarer than 
the idiopathic form. Chronic retro-pharyngeal abscess is due 
to cervical Pott's disease. This occurs in childhood, while the 
above condition occurs almost exclusively during infancy. 

As the lymph-nodes of the retro-pharyngeal space are inti- 
mately connected with the lymphatics of the tonsils and uvula, 
any acute inflammatory condition of these structures may re- 
sult in involvement of the pharyngeal lymphatics. This is 
especially the case during infancy. Later in childhood, how- 
ever, these glands undergo atrophy, for which reason retro- 
pharyngeal suppuration is rare after the third year. 

The tumefaction may be situated in the median line, but 
more frequently it is to one side and may even appear to arise 
from behind one of the half-arches. The glands at the angle of 
the jaw may also be implicated, in which case the swelling is 
found at or beneath the angle of the jaw and in front of the 
sterno-mastoid muscle. In such cases a spontaneous evacuation 
of the abscess externally may take place, although the majority 
break into the pharynx. 

Septic retro-pharyngeal abscess complicating scarlet fever 
and measles shows a tendency to burrow into the mediastinum 



408 DISEASES OF CHILDREN 

or ulcerate into the carotid arteries and other important 
structures. 

Symptoms. — The onset is insidious and usually it is not 
suspected until marked symptoms have developed. The early 
symptoms are those of an upper respiratory infection but in- 
stead of the fever subsiding in the course of a few days it 
continues and the symptoms of pharyngeal obstruction develop. 
There is difficulty of breathing, especially on inspiration; 
crowing respiration, due to inco-ordination of the vocal cords; 
retraction of the head in order to give the larynx as much free 
space as possible and distinctly nasal cry. The child breathes 
with the mouth open and holds the head so rigid that cervical 
Pott's disease or meningitis may be suggested. Inspection of 
the throat will, however, immediately clear away any doubt as 
to the true nature of the case. The abscess is readily made 
out by carefully introducing the index finger into the pharynx. 

If allowed to rupture spontaneously the pus may be as- 
pirated into the lungs, causing suffocation or setting up a septic 
broncho-pneumonia; it may also find its way into the Eu- 
stachean tubes and set up an acute otitis. In many instances, 
however, the pus is swallowed or evacuated through the mouth 
without causing any trouble. Nevertheless, prompt surgical 
interference offers the best prognosis and should be instituted 
in all cases as soon as they give indications for the evacuation 
of pus. 

Treatment. — The abscess is easily incised when it points to 
the median line or not far therefrom. Cases in which the 
swelling is well to the side require greater care, as there is danger 
of wounding the carotid artery. Those pointing externally 
require expert surgical attention. Tuberculous abscesses should 
be opened externally whenever possible. 

The child is held firmly in the upright position and the throat 
illuminated by means of a head-mirror. A mouth-gag is un- 
necessary; all that is required to expose the abscess and keep 
the mouth open is a reliable tongue-depressor. The incision is 



DISEASES OF THE EAR, NOSE, AND THROAT 409 

made toward the median line with a bistoury whose cutting 
edge has been protected by wrapping it with cotton up to 
within half an inch from the point. After making the incision 
it is often necessary to break up septa of connective tissue 
within the abscess cavity with the tip of the index finger. 

The remedies indicated are belladonna in the early stage 
and hepar sulph. when pus begins to form. 

ACUTE RHINITIS; PSEUDO-MEMBRANOUS RHINITIS. 

Acute rhinitis is an acute inflammation of the mucous mem- 
brane of the nasal cavities occurring either as a primary condi- 
tion or secondary to one of the infectious diseases, notably 
measles and influenza. 

Pseudo-membranous rhinitis associated with faucial diph- 
theria is due to the Klebs-Loeffler bacillus in its most virulent 
form, while in those cases in which a diphtheritic membrane 
develops primarily in the nose running a mild course, the bacil- 
lus is present in attenuated form. Such cases, however, 
may give rise to a severe faucial diphtheria, and for this reason 
every case of pseudo-membranous rhinitis should be isolated. 
This attenuated diphtheria bacillus is known as Yon Hoffman's 
bacillus. According to Park {Bacteriology in Medicine and 
Surgery) only in a few cases have other bacteria been 
found to cause the croupous exudate; they were mainly the 
pyogenic cocci. 

There is no doubt that rhinitis is mildly contagious. A 
natural predisposition is found in many cases; this is particu- 
larly the case in anemic children that have been reared like 
hot-house plants and in those suffering from adenoids and 
enlarged tonsils. 

Symptoms. — Following upon exposure, or "catching cold" 
or in the course of an infectious disease a sense of fulness in 
the nostrils with dryness of the mucous membrane develops, 
succeeded by an acrid, watery discharge consisting of serum 
with a small amount of mucus. At this stage the mucous 



410 DISEASES OF CHILDREN 

membrane appears red and swollen, and the entire nasal cavity 
may be occluded by the swollen turbinated bodies. 

In primary cases a slight febrile reaction sets in and there 
is headache, and lassitude. Mild cases may be aborted at this 
stage and resolution occur without any further developments. 
In infants these attacks are spoken of as snuffles, and unless 
they are due to syphilis or are benign, profuse mucopurulent 
secretion makes its appearance, flowing freely from the nose 
and covering over the entire mucous membrane of the naso- 
pharynx. The process may extend to the frontal sinuses, the 
Eustachian tubes and middle-ear, and to' the pharynx. If the 
infection has been of a virulent nature ulceration of the mucosa 
and suppuration of the middle-ear are liable to supervene. 

Pseudo-membrailOUS rhinitis is almost invariably diph- 
theritic in origin, as has been stated above. From the fact that 
constitutional symptoms are usually slight in primary diphther- 
itic rhinitis, it frequently remains unsuspected until the mem- 
brane is accidentally discovered. The membrane may persist 
for weeks, coming away in large pieces. If during its course 
it be removed, it usually recurs. The nose is obstructed, and a 
thin blood-streaked discharge is present. Such a secretion 
should always arouse suspicion of diphtheria. On inspection, 
the membrane is seen as a firm, grayish exudate upon the interior 
of the nose. The clinical course is more benign than that of 
faucial diphtheria but it should receive the same treatment. 

Treatment. — In the early stages the obstruction may be 
much relieved by spraying or douching the nose with a warm, 
mild, alkaline, antiseptic solution, such as Dobell's solution, or a 
normal saline solution, followed by spraying with a bland oil 
containing camphor or menthol in the proportion of two to 
four grains to the ounce. Later, as the discharge becomes 
profuse, frequent cleansing of the nasal passages is imperative. 
In infants or young children who struggle against the use of 
the atomizer, a small glass syringe may be employed, injecting 
into one nostril and allowing the fluid to flow out of the other, 
the child lying on its side during the operation. 



DISEASES OF THE EAR, NOSE, AND THROAT 411 

In the early stages aconite and gelsemium are the most im- 
portant remedies. Hughes (Manual of Therapeutics) considers 
camphor a specific in the early stage, promptly aborting most 
cases and especially relieving the chilly feeling. 

Aconite. — Sneezing; fever with restlessness and full pulse; 
burning of the eyes. Attacks of coryza from exposure to 
draughts or from being chilled. 

Gelsemium differs from aconite in the absence of the restless- 
ness and high fever and in the predominance of malaise ; chilli- 
ness, especially creeps up and down the spine but not a well 
defined chill; headache with drowsiness and heaviness of the 
eyelids; aching in the muscles. Gelsemium is admirably 
suited to the ordinary form of grippe. 

Nux vomica is indicated in the early stages of many cases; 
there is dryness and obstruction of the nose; fulness at the root 
of the nose and frontal headache ; cold hands and feet with a 
hot head ; anorexia and constipation ; irritability of temper and 
feverishness. Subjects who are overly sensitive to draughts. 
In this respect arsenicum is similar. "Persons who are rarely 
without a cold" (Ivins). Sneezing; profuse, watery, excor- 
iating discharge ; tendency of cold to travel down the chest. 

Belladonna has always been a most satisfactory remedy in 
my hands for the vascular engorgement of the turbinated bodies. 
The mucous membrane appears dry and bright red and the 
nose is much obstructed. 

Cepa. — Profuse, acrid watery discharge with lachrymation. 

Euphrasia has a profuse nasal discharge which is bland, but 
an excoriating lachrymal discharge, the opposite condition 
of cepa. 

Sanguinaria canadensis or sanguinaria nitr., 3x trit., is 
useful when there is a sensation of great dryness and burning 
in the nose and pharynx, w T ith headache and loss of smell and 
taste. 

In the second stage, when the discharge becomes profuse and 
muco-purulent in character, no remedy is more useful in the 



412 DISEASES OF CHILDREN 

majority of cases than Pulsatilla. When there is much sore- 
ness of the nose and evidence of ulceration mercurius is the 
better indicated remedy. 

SIMPLE CHRONIC RHINITIS AND PURULENT RHINITIS. 

Chronic rhinitis without pronounced hypertrophic or 
atrophic changes in the nasal mucous membrane is a common 
affection of childhood. 

In the etiology recurrent attacks play an important role. 
The period of childhood itself predisposes to catarrhal inflam- 
mations. Children of the scrofulous diathesis and infants pre- 
senting symptoms of the exudative diathesis are especially 
prone to purulent rhinitis. As a predisposing cause, adenoids 
undoubtedly play a most important role. Unhygienic surround- 
ings, and want of attention during acute attacks or failure to 
guard against the recurrence of such attacks are also responsible 
for many cases. No specific micro-organism is present, but 
there is no doubt that an infection of a mixed character causes 
the purulent inflammation. Irritation by foreign bodies or 
other sources of irritation may induce similar pathological 
changes. 

Symptoms. — The chief symptom is a profuse muco-purulent 
discharge. Nasal obstruction is not pronounced. The nose 
may become reddened about the orifice and excoriated and 
crusts form in the anterior nares, usually at night, in this way 
inducing mouth breathing during sleep. Susceptibility to acute 
attacks seems lessened on account of reduced sensibility of the 
muscosa from loss of epithelial cilia (Ivins). 

Atrophic changes will occur in the course of years if the 
progress be not arrested. It may also pass into the hypertrophic 
variety if rhinorrhea has not been a prominent feature of the 
case. In scrofulous children infection of the cervical lym- 
phatics is a frequent complication. In the majority of cases 
the prognosis is good, especially under proper treatment. 



DISEASES OE THE EAR, NOSE, AND THROAT 413 

HYPERTROPHIC RHINITIS; ATROPHIC RHINITIS. 

Hypertrophic rhinitis is a chronic catarrhal inflammation 
of the nasal mucosa and sub-mucosa, characterized by hy- 
pertrophy of the turbinated bodies with resulting nasal ob- 
struction. It is not as frequently encountered in children 
as in adults, nor is it as common a disease as atrophic 
rhinitis. The pathological changes require a long time for 
their development, being a hyperplasia of the cellular elements 
and overgrowth of the connective tissue and blood-vessels that 
form the turbinated bodies. 

A variety of hypertrophic rhinitis in which there is simply 
engorgement and dilatation of the blood-vessels is not uncom- 
mon. In this class a complete temporary retraction of the 
mucous membrane may be induced by the local application of 
cocaine. 

Atrophic rhinitis , or ozena, is characterized by atrophy of 
the mucous membrane, of the cavernous structures, and the 
underlying bone. There is also atrophy of the mucous glands 
with consequent impaired function and the formation of offen- 
sive crusts. The crusts represent inspissated muco-purulent 
secretion which accumulates in the nasal chambers and under- 
goes decomposition. They are the cause of the fetor emanating 
from these patients. 

Etiology. — Adenoid vegetations play an important role in 
the etiology of hypertrophic rhinitis, by interfering with the 
drainage of the nasal chambers, thus inviting the accumulation 
of irritating material which keeps up a constant congestion of 
the mucous membrane. Again, the constitutional peculiarity 
which invites adenoids and hypertrophy of the tonsils predis- 
poses to chronic catarrh and hypertrophy of the intra-nasal 
structures. Clinically there is an intimate association of these 
conditions. Another cause will be found in recurrent acute 
attacks which may lead up to permanent structural changes. 
Atrophic rhinitis may develop as an independent affection or 



414 DISEASES OF CHILDREN 

as a sequel to hypertrophic rhinitis. Casselberry dissents from 
the latter view, believing the transition of an hypertrophic 
rhinitis an exceedingly rare, and in all events slow process ; and 
he looks upon atrophic rhinitis, particularly in children, as a 
distinct affection. A pronounced hereditary predisposition, 
moreover, has often been observed. Bosworth believes suppura- 
tive rhinitis of children to be the cause of atrophic rhinitis, the 
suppurative process destroying the mucosa layer by layer in the 
course of time, until eventually the deepest structures become 
involved. 

Symptoms. — The chief symptom of hypertrophic rhinitis is 
nasal obstruction. This may be more or less complete and in- 
volve both sides simultaneously or alternately. Remissions 
occur, and frequently the nose will be clear under ordinary 
circumstances, only clogging up when irritated by the inhala- 
tion of dust ; walking in the wind ; entering a warm room, etc. 
This peculiar behavior readily explains itself when we re- 
member that the obstruction depends upon the degree of vas- 
cular engorgement present at the time. 

As a result of the reflex irritation in the nose and the inter- 
ference with respiration, a train of symptoms indicating a dis- 
turbance in the general health of the child arises. Nervous 
irritability; disturbed sleep and mouth breathing; intellectual 
torpor ; hemicrania ; spasm of glottis ; asthma and enuresis, all 
may have their origin in the nasal stenosis. 

On inspecting the anterior nares we will find the turbinated 
bodies swollen and of a deep red color, the inferior turbinated 
being most readily seen and darker in color than the middle or 
superior. If there be much engorgement it will be impossible 
to see more than the inferior body and at the most the anterior 
half of the middle body without making an application of 
cocaine to shrink the mucous membrane. Polypi are likely to 
be confounded with an hypertrophied turbinated body, but they 
are paler in color, are movable, and occupy a position between 
the turbinated bodies. 



DISEASES OF THE EAR, NOSE, AND THE.OAT 415 

Atrophic rhinitis is characterized by the formation of crusts 
and fetor. Obstruction of the nares only occurs if the crusts 
are allowed to accumulate in large masses. They may occur 
simply as scales, or form in large horny masses, completely oc- 
cluding the nasal chamber. These masses eventually soften by 
decomposition or cause necrosis of the underlying mucous mem- 
brane, coming away in large masses and leaving an ulcerated 
surface behind. The fetor may be so intense as to render the 
patient's proximity unbearable. In the beginning the child may 
be annoyed by the odor, but eventually the sense of smell be- 
comes so obtunded that it is not aware of the fetor. There may 
be a sense of distressing fulness in the nose when crusts accumu- 
late, and the habit of constantly picking the nose is soon 
acquired. Epistaxis is soon a frequent accompaniment. The 
general health is naturally affected ; hearing becomes impaired, 
and the sense of smell may be entirely lost. 

Inspection reveals a spacious nasal cavity lined with a thin, 
smooth mucous membrane, covered with crusts. Its surface is 
studded with superficial ulcers. Hereditary syphilis is to be 
differentiated from atrophic rhinitis ; in the former there is not 
a uniform distribution of the atrophic process, and there is deep 
ulceration and cicatrization. Perforation of the septum with 
sinking in of the nose is pathognomonic of syphilis. 

The prognosis is not unfavorable. Under persistent treat- 
ment most cases in children recover, some in the course of a few 
months, others not yielding to treatment in less than a year or 
two. Syphilitic cases, if seen early before destructive changes 
have set in, respond promptly to appropriate local measures in 
conjunction with anti-syphilitic remedies. 

TREATMENT OP CHRONIC RHINITIS. 

In undertaking the treatment of a case of hypertrophic 
rhinitis we must first of all determine whether it is an inde- 
pendent affection or due to adenoid vegetations. If adenoids 
are present they must be removed before the rhinitis can be 



416 DISEASES OF CHILDREN 

benefited. If the condition has not advanced beyond the stage 
of vascular engorgement a cure usually ensues upon the removal 
of the adenoids. When permanent hypertrophy of the turbin- 
ated bodies has set in surgical treatment is indicated. 

Milder cases, not requiring surgical interference, should re- 
ceive local applications of iodine and glycerine (5 per cent.), 
made by means of absorbent cotton on a probe, about twice 
weekly, followed by the use of an oily spray. 

In treating atrophic rhinitis the most rigorous steps for 
maintaining absolute nasal cleanliness must be taken. The free 
use of the douche bag is here to be instituted, and a pint of 
Dobell's solution should be allowed to flow through the nares 
at a time. This should be done twice daily. 

If hard crusts have formed that cannot be dislodged by means 
of the douche, hydrogen dioxid, diluted with warm water 
should be slowly injected into the nares with a blunt syringe; 
this so loosens them that they can be readily blown out. After 
the nose has been cleared a few drops of refined carbon oil with 
iodine (one grain to the ounce) sould be dropped into each 
nostril with a medicine dropper (Kyle). 

When eroded surfaces remain after the removal of the crusts 
a stimulating powder, such as aristol, should be insufflated. 
Syphilitic ulcerations are best controlled by the local ap- 
plication of a ten per cent solution of nitrate of silver. 

Remedies. — When well marked constitutional indications 
are present such remedies as calc. phos., calc. carb. the iodines, 
hepar and silicea will give better results than remedies selected 
purely on local indications. Pulsatilla and hydrastis are espe- 
cially useful in simple, chronic and purulent rhinitis. 

In atrophic rhinitis the chloride of gold, kali bichromicum, 
mercurius corr. and silicea are the most important remedies, 
aurum heading the list. 

Syphilitic affections require mercury, preferably the yellow 
iodide when the ulceration is confined to the mucous mem- 
brane. Ulceration of the septum calls for kali bichromicum. 



DISEASES OF THE EAR, NOSE, AND THROAT 417 

Gummatous infiltration of the soft structures will require the 
iodide of potash in material doses, five grains three times daily 
being the usual dose necessary. 

Alumina. — Thick, greenish-yellow nasal discharge; anosmia; 
mind sluggish ; snapping in the ears when swallowing. 

Arsenicum iod. — Delicate tuberculous constitution; acrid 
discharge with burning in nose. Chronic purulent rhinitis. 

Aurum. — Offensive discharge; soreness of bones of nose. 

Cole. carb. — Glistening redness of nasal mucosa; extreme 
sensitiveness of nose; purulent discharge. Chronic purulent 
rhinitis in scrofulous individuals. 

Calc. phos. — Chronic hypertrophic rhinitis in anemic chil- 
dren or in association with enlarged tonsils and adenoids. 

Hepar. — Chronic purulent rhinitis with enlarged cervical 
glands. Hypersensitive to draughts. Uncovering the body 
brings on attacks of sneezing. 

Hydrastis. — Simple chronic rhinitis and purulent rhinitis. 
Abundant muco-purulent secretion with superficial ulceration 
of the mucous membrane. The discharge may also be stringy 
and tenacious. Post nasal dropping. 

Kali bichromicum. — Tenacious, yellow secretion; ulceration 
of the spetum. 

Natrum mur. — Simple chronic rhinitis. "In all absence of 
clear indications for other drugs this is one of the best remedies 
where persons draw mucus from the posterior nares in the 
morning. " — (Ivins.) 

Pulsatilla. — Chronic purulent rhinitis. Profuse discharge 
which is a bland, thick, yellow muco-pus, streaked at times with 
green. There is loss of taste and smell, and in order to act 
well there must be, according to Ivins, the typical pulsatilla 
temperament. 

Silicea, — Ozena. Painful dryness of the nose; ulceration 

with acrid, corroding discharge (mere. sol.). Thick, fetid, 

post nasal discharge. Periostitis. The silicea patient is pale 

and delicate; predisposed to affections of the glands and bones 

28 



418 DISEASES OF CHILDREN 

that undergo rapid destruction; in other words, it presents the 
tuberculous type. There is also nervous hyperesthesia and 
tendency to neurotic affections. 

ADENOID VEGETATIONS OP THE NASO-PHARYNX. 

The muco-lymphoid glands found in the vault of the pharynx 
and aggregated into a tonsil-like organ known as the tonsil of 
Luslika, or the pharyngeal tonsil, are in their normal state of 
insufficient size to be readily demonstrated, or to cause inter- 
ference with free nasal respiration. Under certain conditions, 
however, they become much enlarged; in some instances a 
hypertrophy of such extent takes place that they fill up the 
entire naso-pharyngeal space, thus effectually preventing nasal 
respiration and giving rise to the pernicious habit of mouth 
breathing. 

~No definite cause can be blamed for the development of this 
hypertrophic condition, as it is encountered in children of all 
descriptions, although the so-called scrofulous diathesis, and 
the status lymphaticus are the most frequent constitutional 
peculiarities found associated with hypertrophied adenoids. 
During childhood the lymphatic structures throughout the 
entire body are in a state of active growth and function and 
there is a normal tendency for lymphoid tissue to become hyper- 
plastic at this age. As in the case of enlarged tonsils, there is a 
distinct family tendency to hypertrophied adenoid tissue and 
although the two conditions usually coexist, still it is not 
uncommon to> see children with adenoids whose tonsils are 
small or rudimentary. 

Chronic nasal catarrh; deflections of the septum; the exanthe- 
mata, and a damp, changeable climate furnish the causes which 
excite the hypertrophy of the adenoid tissue. 

The pathological changes encountered in the mucous mem- 
brane of the pharynx are an overgrowth of the muco4ymphoid 
follicles and of the connective tissue in which they are embed- 
ded, together with increased vascularity and thickening of 



DISEASES OF THE EAR, NOSE, AND THROAT 419 

the mucosa. This hypertrophy leads to the formation of a 
large glandular mass which may attain sufficient size to entirely 
block the naso-pharynx. According to the amount of connective 
tissue present and the mode of proliferation of the glandular 
elements, there will be either a soft, papillomatous growth, or 
a hard, smooth mass, known as the individual variety, in 
contradistinction to the papillomatous, which is a multiple, 
pear-shaped mass. The individual variety is smooth and firm, 
while the papillomatous is soft and irregular in contour, convey- 
ing the impression of a bunch of earth worms to the examining 
finger. 

Adenoid vegetation belongs practically to the period of 
childhood, and after full maturity a physiological atrophy as 
a rule sets in, the pharyngeal vault being usually smooth in 
adults. 

Symptoms. — Chronic nasal and pharyngeal catarrh is usually 
associated with adenoid vegetations, especially when they have 
existed for a long time. While a catarrhal affection of the nose 
and pharynx no doubt often acts as the exciting cause of 
adenoid tissue proliferation, still adenoids in themselves will 
set up catarrh through their mechanical interference with the 
circulation and normal breathing. The obstruction of the naso- 
pharynx leads to lack of development of the frontal, sphenoidal, 
maxillary and ethmoidal sinuses with consequent narrowing of 
the face and upper jaw, which, together with the increased 
atmospheric pressure exerted upon the buccal surface of the 
palate due to lessened intra-nasal air-pressure and mouth breath- 
ing, leads to a gradual forcing up of the arch of the palate. 
This deformity results in turn in deflection of the nasal septum, 
on account of the upward crowding of the base of the septum. 
In this manner the nasal obstruction is still further augmented 
and hypertrophic rhinitis is invited. 

Deafness from direct pressure upon the ostia of the Eus- 
tachian tubes or through an extension of the catarrhal process 
into the tubes is a frequent symptom accompanying adenoids. 



420 DISEASES OF CHILDREN 

The physiognomy is characteristic and practically pathog- 
nomonic, and taken in conjunction with the alteration in voice 
and impaired hearing makes the diagnosis possible on these 
data alone. The upper lip becomes shortened from lack of 
development as a result of keeping the mouth open ; the expres- 
sion of the face is vacant and stupid; the nose is pinched and 
undeveloped and owing to the contraction of the superior 
maxilla the permanent teeth become irregular in distribution. 

When the condition has arrived at this stage there results as 
a natural consequence of the interference with the proper 
aeration of the blood a serious disturbance in the child's general 
health. Anemia, flat chest and constant colds make the child 
neurasthenic and may predispose it to pulmonary tuberculosis. 
The lack of normal physical vigor and the impaired hearing 
make the child backward at school and frequently stamp it 
as being mentally sub-normal. 

A stubborn nocturnal cough is frequently present. Restless 
sleep, snoring, night-terrors and enuresis all suggest adenoids. 
Recurring attacks of earache is another common symptom. 

Diagnosis. — The presumptive evidence of adenoid vegeta- 
tions is found in the facies and the nasal, non-resonant voice 
together with the associated symptoms of mouth breathing; 
nasopharyngeal catarrh; partial or total deafness and retarded 
nutrition. Naturally these symptoms are only to be encountered 
in well-advanced cases; in incipient cases the age of the child 
and the development of the nasal obstructions, not springing 
from an abnormal condition of the nose proper, should always 
arouse a suspicion of adenoid vegetations. The positive evi- 
dence of adenoids is obtained through posterior rhinoscopy. 
This procedure is quite diflicult, practically impossible with 
some children. In others, however, a very satisfactory view of 
the vault of the pharynx may be obtained. Anterior rhinoscopy 
is usually the most satisfactory method of examination. The 
inferior turbinated body should be shrunken by the application 
of a weak solution of cocaine with adrenalin after which the 



DISEASES OF THE EAR, NOSE, AND THROAT 421 

posterior nares can be inspected. The adenoid tissue is seen 
in the post-nasal space as an irregular mass lighter in color than 
the surrounding mucous membrane and when the child swallows 
or is made to say "e" it moves upward with the elevation of 
the palate. 

Digital examination is a crude and not altogether satisfactory 
method and should only be used as a last resort. 

The treatment of adenoids is purely surgical. While con- 
servative measures may be tried in the case of enlarged tonsils, 
there is nothing to be gained by postponing the removal of 
adenoid vegetations. Adenectomy is therefore indicated as 
soon as the presence of adenoids is clinically recognized. 



CHAPTER XVI. 

DIATHETIC AND CONSTITUTIONAL DISEASES. 
MARASMUS, OR ATHREPSIA; MALNUTRITION. 

The extreme form of infantile malnutrition, designated mar- 
asmus, is a rare condition and is more often seen in hospitals and 
dispensaries than in private practice. There is a form of mal- 
nutrition, however, which is less extreme in type and which is 
far more common, being a purely dietetic disturbance resulting 
from improper feeding. Cases of this class are more hopeful and 
usually respond promptly to treatment in contradistinction to 
true marasmus in which the prognosis is less favorable. 

Marasmus was first described by Parrot in 1877, who desig- 
nated it "infantile athrepsia." The etiological factors may be 
a congenital debility or a congenital lack of tolerance for cow's 
milk and the failure of the child to thrive on artificial food may 
be noted from the time of birth. In some instances the infant 
gives a history of having gained weight progressively for a 
time and then come to a standstill with symptoms of dyspepsia 
and constipation. A further increase of the food under these 
circumstances leads to a corresponding loss of weight due to the 
child's intolerance for the fat of cow's milk. Other cases can 
be traced to chronic indigestion from overfeeding with carbo- 
hydrates, especially sugar. Condensed milk, with its low 
protein and high sugar content is often responsible for 
such cases. 

The histological findings in the gut are not characteristic. 
Baginsky insists that the mucosa is thinner than normal and 
that there is distinct evidence of atrophy of the intestinal 
tubules and villi. Huebner, on the other hand, claims that 
pathological changes are not constantly found and when so, 
that they are only the evidence of a preceding enteritis. 

On the other hand, the long-continued distention of the gut 



DIATHETIC AND CONSTITUTIONAL DISEASES 423 

with gas, as a result of fermentation accompanied by the 
wasting of its muscular coat produces the appearance of a 
glandular atrophy. The careful investigations of Holt substan- 
tiate the view that there is no definite gross pathological lesion 
in the intestinal mucous membrane to account for the clinical 
manifestations. 

The theory of a chronic acid intoxication (acidosis) of 
intestinal origin was first advanced by Keller, who found the 
urine highly acid and containing an excess of ammonia. The 
origin of these acids lies in a deficient oxidation of the carbo- 
hydrates and particularly the fats of the ingested food. The 
excessive elimination of alkaline salts through the intestinal 
mucosa, which unite with the fatty acids in the intestine, also 
contributes toward the production of this relative acidosis. 

Arguing from the established fact that the intestinal mucosa 
of a marantic infant assimilates the proteids and fats of an 
artificial food much less satisfactorily than breast milk and 
consequently expends a much greater amount of glandular 
energy in this attempt, Huebner explains the failing nutrition 
on the grounds of a disturbed balance of energy (Balance 
Disturbance); in other words, waste of energy on the part of 
the organism. There is also a loss of mineral salts through the 
intestinal tract and an increased elimination of nitrogen by the 
kidneys leading to "Decomposition" (Finkelstein). Loss of 
fluid and a tendency to dessication is also of great clinical 
importance in these cases. In a number of cases of severe 
malnutrition and marasmus I have found a marked deficiency 
of hydrochloric acid in the gastric contents. 

The etiology of marasmus is not always clear. In some 
infants there is undoubtedly a congenital feebleness of constitu- 
tion which renders them incapable of conquering in the struggle 
for existence. Here heredity is an important factor, and we 
may find evidence of constitutional disease in the parents; on 
the other hand, they may be perfectly healthy. Extreme youth 
of the mother, and frequent pregnancy at short intervals is 



424 DISEASES OF CHILDREN 

often noted on the material side of the history. The surround- 
ings play an important role. Crowded quarters and lack of 
fresh air and sunshine are strong contributing factors. The 
ordinary hospital ward is a most undesirable quarter for infants 
convalescing from an acute illness and unless promptly removed 
therefrom they soon show signs of failing nutrition. 

Symptoms. — The infant may be delicate at birth, have 
difficulty in digesting its food even when breast-fed, and its 
weight curve show a progressive loss of weight interrupted by 
periods of temporary gain or stand still. More frequently the 
infant appears normal at birth and gets on perhaps as well as 
the average one up to the third or sixth month, when, as the 
result of some acute illness, or what is more common, repeated 
attacks of indigestion, it loses all tolerance for food and goes 
into a decline, or "decomposition." It is by no means necessary 
that the infant should have been on breast milk and that a 
change to artificial feeding be instituted in order to bring about 
this condition. A sudden change during artificial feeding to 
an ill-selected diet or the more gradual ill-effects from a diet 
that contains too much sugar or fat will accomplish the same 
results, especially when the environment is such as to favor 
marasmus. The emaciation progresses until the infant is 
reduced literally to skin and bones. The skin is thin and 
wrinkled and there is a pronounced pallor. Cyanosis is often 
noted. The face has an old, wrinkled appearance, the eyes 
being sunken and the small triangular chin showing in marked 
contrast to the large head; the chest is small and the ribs are 
plainly visible while the abdomen is flabby and wrinkled or 
distended. Through the thin abdominal wall the stomach 
and coils of dilated intestines can often be seen. Impacted 
fecal matter can often be palpated in the colon. The skin is 
pale and transparent. There is more or less intertrigo about 
the genitals and buttocks and a few scattered boils are not 
uncommon. The urine is ammoniacal and unless great care is 
taken causes erythema, papules and vesicles on the skin of the 
buttocks, back and legs. 



DIATHETIC AND CONSTITUTIONAL DISEASES 425 

The temperature is sub-normal and the pulse is weak and 
slow. A slight fever may be present from indigestion. Edema 
of the face and extremities may develop without any evidence 
of a renal complication. 

The stools vary in character. To all appearances they may 
be normal, excepting that an excess of fatty acids and calcium 
soap may be demonstrated. Cases of balance disturbance from 
fat overfeeding, develop the characteristic large, pale, dry, 
alkaline soap stools. Cases with sugar dyspepsia have frequent 
acid stools. Alternate constipation and diarrhea may occur. 

The appetite is variable. Sometimes for a considerable 
period it is voracious and the child does not seem to get satisfied. 
Then, again, it may be lost and there may be difficulty in 
inducing the infant to take sufficient nourishment. Trouble- 
some vomiting frequently adds to the gravity of the condition. 

The duration is difficult to foretell. The child may die from 
an intercurrent diarrhea or bronchopneumonia, or it may 
suddenly go into a collapse from which it cannot be resuscitated. 
On the other hand, progressive improvement may follow under 
improved hygienic surroundings and proper dietetic manage- 
ment. Under the best conditions, however, the cure will be 
slow and the physician and parents must show both patience 
and perseverence. 

The prognosis is always grave, but it depends much upon 
the care the child can receive. Many of the cases that die 
annually could be saved if they could be removed to more 
favorable surroundings and receive more skillful and conscien- 
tious nursing. Persistent watching and self-sacrifice on the 
part of the mother or nurse will often apparently accomplish 
the impossible in these cases. 

Diagnosis. — The differentiation between marasmus and 
tuberculosis may present difficulties. It is said that the tuber- 
culous infant is bright in appearance and not so prostrated and 
apathetic as the marantic infant, but this is not a reliable sign. 
In tuberculosis we have continued fever as a more or less con- 



426 DISEASES OF CHILDREN 

stant symptom. Furthermore, repeated careful examinations 
of the chest will ultimately reveal evidence of tuberculosis and 
we may also be able to detect enlarged mesenteric glands by pal- 
pation of the abdomen. Persistent diarrhea with pus in the 
stools and at times blood speaks strongly for tuberculosis. A 
history of tuberculosis in the parents or of exposure to tubercu- 
losis is suggestive of tuberculosis. Finally, a positive von 
Pirquet reaction is definite clinical evidence of an active tuber- 
cular infection at this time of life. 

Hereditary syphilis must be excluded in all cases of mal- 
nutrition in infancy before a diagnosis of marasmus can be 
made. The characteristic symptoms and stigmata of this disease 
may be absent and wasting and anemia may be the only evi- 
dence of a serious constitutional disturbance. A Wassermann 
test should therefore be made in all doubtful cases. 

Malnutrition is a much commoner condition than marasmus. 
It may be the result of premature or inherited feebleness of 
constitution, or follow after some acute illness, notably a gastro- 
intestinal affection. Again, malnutrition is a prominent symp- 
tom in tuberculosis, syphilis and rickets. 

Its most usual cause is improper feeding and unhygienic 
surroundings. As to the last named factors, they are just as 
likely to be encountered in well-to-do families as among the 
poorer classes, for here proprietary foods and close, overheated 
nurseries may be etiological factors. In older children anemia 
and malnutrition often date back to an attack of one of the 
infectious diseases or result from improper eating and hygiene 
(see Chronic Intestinal Indigestion). The diagnosis of simple 
malnutrition rests upon the exclusion of an organic disease 
or infection of which it might be only symptomatic. 

Treatment. — The regular weekly weighing of the infant 
is an absolute necessity and the only accurate guide by which 
we can judge of the progress of the case. Whenever a weight 
disturbance occurs, the evening and morning temperature 
should be taken regularly, as this will indicate whether or not 



DIATHETIC AND CONSTITUTIONAL DISEASES 427 

we must resort to artificial heat or extra clothing; also whether 
the infant must be kept in bed or taken out in the fresh air. 
With a persistently sub-normal rectal temperature I have found 
it best to keep the infant in its crib well clothed and a hot water 
bag at the feet. Such infants should not be bathed but gently 
washed and then rubbed with warm olive oil. Very young 
infants who are too much exhausted by dressing and undressing 
can be wrapped in raw cotton. 

Dietetic treatment. — If the infant be breast fed we must 
determine by examination of the milk whether it is sufficient 
in amount and of proper chemical composition. If the milk be 
at fault and appropriate treatment applied to the mother does 
not improve the same, we must try a wet nurse. If the milk 
is simply deficient in quantity, mixed feeding should be 
instituted. 

As it is not always possible to obtain a wet nurse, we should 
bear in mind that in modifying the milk for a delicate or 
marantic infant it must be of a strength that would be suitable 
for a much younger infant than the one in question. 

In the artificial feeding of a marantic infant a reduction of 
the fat in the food is of first importance. This applies especial- 
ly to cases in which constipation is a prominent symptom. 
When the symptoms are extreme and of long standing the best 
mode of procedure is to put the infant on churned buttermilk 
or fat-free lactic acid milk for about a week after which time 
a change to Keller's Malt Soup may be advantageously made. 

Cases in which diarrhea is present do best on Finkelstein's 
Eiweissmilch. After the intolerance to sugar has been over- 
come a carbohydrate, preferably Dextri-maltose, may be added. 
This should be added in small amounts (one level tablespoonful 
to 24 hour quantity of food) and gradually increased to three 
level table spoonfuls in 24 hours. 

Another food which frequently gives excellent results in 
cases showing marked intolerance to the fat of ordinary milk 
modifications is the Czerny-Kleinschmidt butter-flour mixture. 



428 DISEASES OF CHILDREN 

This may be prepared as follows : Two tablespoonfuls of butter 
are boiled for five minutes over a slow fire to drive off the 
volatile fatty acids and then two tablespoonfuls of wheat flour 
are stirred into the butter and twenty ounces of water are 
added. Tnis is allowed to cook slowly for five minutes, occasion- 
ally stirring the mixture, after which ten ounces of previously 
boiled whole milk are added. Cane sugar may gradually be 
added beginning with one teaspoonful and increasing to two 
level tablespoonfuls. 

An important point to bear in mind in feeding a marantic 
infant is to give it relatively small quantities of food at long 
intervals (4 hours) until its food tolerance has been restored. 
Even though the above mentioned foods are well adapted to the 
delicate digestion of such a case, still they must be cautiously 
administered and overfeeding with the same is to be strictly 
avoided. A rapid gain in weight must not be anticipated or 
expected until the infant's assimilation has been decidedly and 
permanently improved. A grave mistake which is often made 
is to attempt to feed these infants according to their caloric 
requirements and give them from fifty to sixty calories per 
pound of body weight. The invariable result is to aggravate 
the dyspepsia and cause them to lose more weight. We should 
be satisfied if these infants maintain a stationary weight for a 
time or make only a slight gain until their digestion has 
improved and they are in a condition to be fed up. 

Stimulation is at times called for. A few drops of brandy, 
well diluted, given during periods of great depression, has 
seemed helpful. Panopetone may also be tried. 

On account of the anemia, freshly prepared beef juice 
(diluted) should be given in small quantities daily (one to two 
teaspoonfuls). Diarrhea may temporarily contraindicate its 
use. We know that even human milk contains insufficient iron 
to supply the requirements of the organism after a certain 
period, as has been pointed out by Bunge, and that the infant 
actually draws from the store of iron present in its tissues at 



DIATHETIC AND CONSTITUTIONAL DISEASES 429 

birth to sustain the hemoglobin percentage of the blood. Con- 
sequently anemia develops if milk is continued as the sole food 
beyond a certain time, and more markedly in subnormal than 
in normal infants. Orange-juice should also be given for 
obvious reasons. Occasionally small amounts of cod liver oil 
will be tolerated and assimilated when cream has to be entirely 
eliminated from the diet. 

In looking over the list of remedies recommended in disorders 
of nutrition, the deep acting constitutional ones stand in the 
foreground. Much benefit is derived, however, from paying 
attention to the acute symptoms as they arise and prescribing 
such remedies as nux vomica, podophyllum, ipecac, etc., inter- 
currently. 

The calcareas seem indicated in the majority of cases, espe- 
cially cole. phos. which is best indicated in undersized, marantic 
infants who give a history of previous attacks of diarrhea and 
congenital debility. Cole. carb. is better indicated in cases re- 
sulting from fat intolerance in which there is constipation of 
large putty-like stools, prominent abdomen and sweating about 
the head. Alumina should also be thought of in cases with ob- 
stinate constipation. Iodine is strongly related to emaciation 
and glandular atrophy, and the iodides are often indicated, 
especially the iodide of arsenic, when there is great prostration, 
nervous irritability and restlessness; tendency to diarrhea; 
dropsical swelling of the face and extremities. 

Sulphur presents many of the symptoms of marasmus, and 
it suits especially the cases with cutaneous eruptions; inter- 
trigo; irritating stools and urine (exudative diathesis). Mer- 
curius is of decided value in cases presenting symptoms sug- 
gestive of syphilis. 

Lycopodlum and natrum muriaticum are important in mal- 
nutrition and emaciation, and will be suggested by their char- 
acteristic symptoms. Lycopodium has a dark-colored urine 
which stains the diaper and which becomes strongly ammoniacal 
at times. The child is voracious, exceedingly irritable and 
there is much abdominal distention. 



430 DISEASES OP CHILDREN 

RICKETS; RACHITIS. 

Rickets is a chronic nutritional disease of childhood in which 
there is a pathological standstill in the normal process of ossifi- 
cation, with resulting softening and deformity of the entire 
osseous system. Malnutrition and certain general disturbances 
are associated with the osseous changes. 

Rickets belong to the "deficiency diseases" probably resulting 
from a deficiency or total absence in the child's diet of the fat- 
soluble vitamin (vitamin A) which is found in the fat of fresh 
raw milk. Prolonged heat destroys this vitamin for which 
reason rickets is frequently encountered in infants fed upon 
proprietary foods, condensed milk and boiled or sterilized milk. 
Rickets may develop in infants at the breast if the mother's 
milk is deficient in fat or if the nursing is prolonged beyond the 
normal period. It is readily induced in young growing animals 
by feeding them upon a diet deficient in the fat-soluble vitamin. 
Mellanby {London Lancet 1919) succeeded in producing 
rickets in young dogs through depriving them of fat-soluble 
vitamin A. Hess and Unger {Jour. Amer. Med. Asso., 1920) 
opposed the theory of avitaminosis as a cause of rickets in the 
human being on the grounds of not being able to improve their 
cases of rickets by means of a diet rich in vitamin A. Recently, 
however, Park and Howland {Johns Hopkins Hospital Bull.; 
1921) have given both radiographic and clinical evidence of 
the uniform and consistent improvement which occurs in rickets 
from the administration of cod liver oil. They state that the 
changes in the bones which are brought about through the ad- 
ministration of cod liver oil amount to a complete cure, pro- 
viding that the diet is not too faulty. The presumption is that 
the curative effect of the cod liver oil depends upon the fat- 
soluble vitamins which it contains rather than upon the oil 
itself. 

Hereditary predisposition to rickets no doubt exists. The ma- 
jority of infants escape the development of rachitic manifesta- 



DIATHETIC A!NT> CONSTITUTIONAL DISEASES 431 

tions because they have obtained, through the fetal circulation, 
sufficient vitamin to maintain normal nutrition until they are 
weaned and put upon a mixed diet. Infants who lack this 
protective inheritance begin to show signs of rickets after the 
sixth month unless the diet is an exceptionally favorable one, 
namely one rich in fresh butter fat. 

Eickets is essentially a disease of infancy. The earliest symp- 
toms usually manifest themselves at the sixth month. If the 
condition progresses the disease will be fully developed when 
the child is a year old. Rarely the symptoms develop during 
the second year and persist into the third year. The so-called 
fetal rickets is not rickets but is a term sometimes used erron- 
eously to designate cases of achondroplasia and myatonia 
congenita. 

Unhygienic surroundings, poor ventilation, and insufficient 
fresh air and sunshine are important factors acting as pre- 
disposing causes. Geographically, rickets is confined to the 
temperate zone and is common among the Italians and negroes 
in the tenement districts of the large cities. Lack of sunshine 
is unquestionably a potent contributing factor in conjunction 
with insufficient fresh air. The greater prevalence of rickets 
during the winter months, its less frequent occurrence in south- 
ern countries and the beneficial effect of sunlight in the treat- 
ment of the disease, bear out this theory. 

Pathology. — The earliest pathological disturbance encoun- 
tered in rickets begins in the periosteum. This accounts for the 
general sensitiveness of the body and the disinclination on the 
part of the child to use its extremities and its discomfort on 
being handled. In the bones we find an irregular growth and 
distribution of the osteogenetic cells in the centres of ossifica- 
tion together with absorption and irregular deposit of lime salts. 

The chemical composition of the bones is much altered. 
Thus, in the shaft of the tibia there is normally 21 per cent 
water, in rickets 45 per cent. In the ribs the percentage of 
water may be raised from 44 per cent (normal) to 66 per cent. 



432 DISEASES OF CHILDREN 

The most important alteration, however, is the decrease in cal- 
cium phosphate. The ash (mineral constituents) may fall from 
60 per cent, which is about the average in normal bone, to 30 
per cent or even lower. Such a bone can be readily bent or cut. 

The first demonstrable microscopical changes take place in the 
periosteum, being in the nature of an abnormal proliferation 
of its cells. In the medullary canal, a fibro-cellular hyperplasia 
takes place which invades and replaces the medullary substance. 
The same process may affect the epiphyseal portion of the bone 
or even the diaphysis, leading to thickening and structural 
changes. 

At the extremity of the long bone, where the shaft and epiphy- 
sis are joined, growth is most active, for it is by the formation 
of new bone from the proliferating cartilage cells and their 
ultimate calcification that the bone increases in length. At 
this point rickets shows its most marked effect upon osteo- 
genesis. The proliferating zone of cartilage cells is increased 
as are also the rows of cartilage-cells columns, which at the same 
time lose their regular arrangement. The zone of temporary 
calcification encroaches upon the upper layers of the cartilage 
and becomes interspersed with a net-work of blood vessels, islets 
of uncalcified cartilage and osteoid tissue. 

In the medullary canal of the shaft, absorption of lime salts 
takes place, the canal becoming abnormally large and the 
marrow being replaced with fibro-cellular and vascular tissue. 
The outer layers of the bone become thickened through ex- 
cessive proliferation of the periosteum and the production of 
osteoid tissue. In the flat bones, particularly in the occipital 
bone, absorption of osseous tissue in small areas results in the 
production of craniotabes. 

These alterations in the structure of the bone explain its 
alteration in shape namely the thickening of the shaft and the 
clubbing of the extremities, and also account for the pliability 
and consequent deformities of the long bones. 

With the arrest of the rachitic process, calcification of the 



DIATHETIC A:NT> CONSTITUTIONAL DISEASES 433 

cartilage sets in and the bone may become abnormally bard. 
The hypertrophic tissue in the centres of ossification and along 
the epiphyseal lines is absorbed to a great extent so that the 
only permanent deformity which ultimately remains, is the 
distortion and bending of the bone that took place during its 
soft stage. 

The soft structures of the body contain a normal amount 
of lime salts. 

Pathological changes in other organs are not characteristic 
and constant. The liver may be enlarged. Splenic enlarge- 
ment, due to simple hyperplasia, is not uncommon. Anemia 
may be pronounced. Catarrhal processes in the gastroin- 
testinal tract and in the lungs may be associated with rickets. 

Symptoms. — The typical symptoms of rickets are the 
osseous changes and deformities. These are, however, late 
manifestations of the disease. An early diagnosis of rickets 
rests upon a knowledge of the early general disturbances which 
should always be looked for in artificially fed infants. 

Rickets seldom develop before the sixth month, being prac- 
tically a disease of the first dentition period. Its onset is 
usually associated with dyspeptic symptoms, moderate range 
of fever, fretfulness, restlessness with tendency to kick off the 
covers, and excessive sweating. Sweating is most pronounced 
on the head but the body is often covered with sudamina and 
a miliary rash. The development of anemia, debility, pro- 
fuse sweats and general sensitiveness of the body are indica- 
tions of the onset of rickets. Constipation with abdominal 
distention is a characteristic late manifestation due to intestinal 
atony. Rolling the head from side to side until the hair has 
been rubbed from the scalp in the occipital region is another 
characteristic symptom. The hair is abnormally dry and brittle 
and is thus readily shed. 

The entire muscular system is in an enfeebled undernour- 
ished condition. This accounts for the constipation, weak heart 
with sluggish circulation, and the rachitic pseudo-paralysis. 
29 



434 DISEASES OF CHILDREN 

This latter condition results from the ligamentous laxity, mus- 
cular feebleness and the soft condition of the bones. 

The first bone changes are usually found in the ribs. As 
the disease progresses the epiphyses of the long bones become 
involved. There is,however, no fast rule as to sequence in the 
development of the deformities, and it is rare to find all of the 
characteristic lesions in an individual case. The ribs become 
beaded in their anterior extremity, at the junction of the rib 
with the costal cartilage. This deformity is described as the 
rachitic rosary,, and it can be demonstrated in almost every case 
on post-mortem dissection as well as recognized by palpa- 
tion during life. Sometimes the rosary can be plainly seen. 
Owing to the softening of the ribs, the thorax becomes com- 
pressed laterally, with resulting projection of the sternum ; 
this is the pectus carinatum, or chicken-breast. Another de- 
formity of the chest is a groove encircling the lower portion 
of the thorax, the so-called Harrison's groove. This line cor- 
responds with the lower border of the lungs and it is produced 
by recession of the lateral region of the soft, yielding thorax 
from atmospheric pressure, and the eversion of its lower border 
due to the large, distended abdomen. These deformities become 
especially prominent as a result of diseases of the respiratory 
tract. 

Affections of the cranial bones are among the earliest signs 
of rickets. Softening of the occiput, with areas of craniotabes, 
can be demonstrated, especially in the region of the lambdoital 
suture. The occipital region becomes flattened as a result of 
the child lying on its back. The sutures are late in closing, 
the fontanel abnormally large, and the frontal and parietal 
centres of ossification are prominent. These developmental 
peculiarities give to the head a large, square appearance, very 
typical of rickets. The head may also become misshapen and 
asymmetrical from lying more on one side than upon the other 
during the stage when the bones are soft and yielding. 

The softness of the bones of the palate and of the jaw pre- 



DIATHETIC AND CONSTITUTIONAL DISEASES 435 

disposes to the development of deformities from the act of 
sacking and mastication. 

The spinal column suffers more or less in all cases of rickets. 
Owing to the softness of the vertebrae and weakness of the spinal 
muscles and lax ligaments, the child develops a kyphosis, when 
sitting up, which may result in a permanent deformity if the 
condition is not recognized and corrected. Rachitic kyphosis 
presents a curved outline, involving the greater portion of the 
spinal column, and in its early stages it can be entirely re- 
duced by laying the child upon its stomach and making traction 
on the spine by lifting it up by the legs. The deformity of 
Pott's disease is permanent, angular in outline and involves 
only one or two vertebra?. Scoliosis may also develop in the 
rachitic infant. 

The extremities suffer from bending and twisting, as a result 
of muscular traction and the weight of the body. The humerus 
and tibia suffer most frequently. Serious deformity of the pel- 
vis rendering parturition difficult or even impossible is one of 
the unfortunate late results of rickets. 

The eruption of the teeth is delayed and irregular, and they 
may decay early on account of a deficiency of or irregular 
deposit of enamel. Rachitic teeth are typically ridged in their 
axis and sometimes present a saw edge. They must not be 
mistaken for syphilitic teeth. 

Rachitic children show a marked predisposition to a variety 
of ailments, referable to the nervous system, the alimentary 
tract, the skin and mucous membrane. They are also subject 
to catarrhal disturbances and to bronchitis. 

Among the disturbances of the alimentary tract complicating 
rickets, chronic indigestion, chronic intestinal catarrh and 
obstipation are of the most common occurrence. 

The nervous system is particularly unbalanced and highly 
susceptible to peripheral impressions. Trifling ailments are 
liable to be ushered in with convulsions, and, in fact, convul- 
sions occurring after the first year should always lead to a 



436 DISEASES OF CHILDREN 

suspicion of rickets. Spasm of the glottis and tetany occur 
more frequently in rachitic infants than in non-raehitic. There 
is a close relationship between spasmophilia and rickets owing 
to the fact that both present as an underlying condition a 
serious disturbance of calcium metabolism. 

The alterations in the blood are not constant and uniform. 
In all cases more or less anemia is present, and in some, especial- 
ly those with splenic tumor, there may be leukocytosis with 
abnormal elements (myelocytes; mast-cells and normoblasts) 
in the blood. The hemoglobin and red cells are diminished in 
varying proportions. 

The course of rickets is chronic but the early institution of 
treatment, together with the favorable influence of fresh air 
and sunshine, will, as a rule, bring about prompt amelioration 
of the symptoms. 

The differential diagnosis lies between hereditary syphilis; 
hydrocephalus; Barlow's disease or infantile scurvy; and 
Pott's disease. The differentiation from the last condition has 
already been considered above. Barlow's disease is a more 
acute disease, more frequently found in infants of the better 
classes as a result of exclusive feeding with proprietary foods, 
and is attended by swelling of the shafts of the bones from sub- 
periosteal hemorrhages; joint tenderness and swelling and 
ecchymoses in various parts of the body and hematuria. Scurvy 
is frequently associated with rickets and it should be suspected 
when the rachitic symptoms become acute in character. 

Epiphyseal disease and separation is a symptom of congenital 
syphilis, which, however, occurs in the earliest months of life, 
other signs of syphilis being demonstrable. 

Chronic hydrocephalus presents a head more rounded than 
the rachitic cranium; the face is disproportionately small in 
comparison with the head; the eyeballs are deflected down- 
wards, and the mental condition is one of dullness and imbecility 
rather than precocity, as in rickets. 

The prognosis is favorable if the disease is recognized 



DIATHETIC AND CONSTITUTIONAL DISEASES 437 

early and if proper treatment can be carried out. An uncom- 
plicated case without pronounced deformity of the chest, anemia 
and splenic tumor is generally promptly amenable to> treatment, 
while those with such unfavorable symptoms especially in 
conjunction with laryngismus stridulus present a more serious 
prognosis. The occurrence of pneumonia or whooping-cough 
in a rachitic infant is a grave complication. 

Treatment. — Prophylactic measures should be instituted 
during pregnancy if a hereditary predisposition to rickets has 
been noted. The mother should take a diet containing sufficient 
milk, cream and green vegetables to supply the fetus with the 
necessary vitamins. The use of condensed milk and proprietary 
foods in the child's diet, in the place of modified fresh cow's 
milk, should be discouraged. The early addition of fruit juices 
and vegetable broths to the infant's diet should be prescribed. 
Ample fresh air and sunshine are absolutely essential to the 
infant's welfare. 

Cod liver oil, owing to its vitamin content, is an excellent 
addition to the diet and may be looked upon as a specific for 
rickets. The raw yolk of egg may also be used with advantage. 

In the early stages of rickets calc. phos. is the chief remedy. 
The scrawny, under-developed infant, with flabby abdomen; 
diarrheal stool containing greenish mucus, undigested casein 
and fat particles; delayed teething and large fontanel; closely 
corresponding to the incipient period of the disease. Later on, 
as the osseous changes, the anemia, local sweating about the 
head and the distended abdomen become prominent symptoms, 
calc. carb. is more applicable. 

Kassowitz demonstrated that phosphorus exerts a specific, 
selective action upon the epiphyses of the long bones, inducing 
an inflammatory process of the bone-forming cartilage at this 
point thus presenting a strong similarity to> the rachitic process. 
On the strength of this he was the originator of the "phosphor- 
therapie" in rickets, being championed by such pediatrists as 
Demme, Soltmann, Jacobi and others. Phosphorus may, there- 



438 DISEASES OF CHILDREN 

fore, be confidently used as a homeopathic remedy for rickets. 
Babinsky has observed that it is most helpful in cases with 
laryngismus stridulus. 

Ferrum phos. is a valuable remedy for the acute respiratory 
disturbances of rickets. It is also useful in the anemia of 
rickets and may be used in conjunction with calcarea phos. 
in the early stages of the disease. 

The following remedies should be studied for special in- 
dications: 

Alumina. — Abnormal cravings or voracious appetite; open 
fontanels; distended abdomen; obstipation, from inactivity of 
the rectum. 

Bell. — The nervous manifestations of rickets frequently call 
for this drug. 

Kali hydrojod. — Preliminary symptoms of rickets. Tender- 
ness of the entire body, but especially about the head (Cooper). 

Mercurius. — Cases with a syphilitic family history. 

Silica, — Profuse sweating about the head and chest, with 
general sensitiveness of the body; anemia; pale skin through 
which the bluish veins are prominently seen; swelling of the 
epiphyses of the bones and affections of the cartilages in gen- 
eral; skin dry and scaly, with tendency to suppurative affections, 
notably paronychia ; imperfect assimilation ; child is slow in 
walking. 

INFANTILE SCURVY; BARLOW'S DISEASE. 

Infantile scurvy, also known in the literature as Barlow's 
disease, is a chronic nutritional disturbance belonging to the 
deficiency diseases which develop as the result of a diet deficient 
in antiscorbutic vitamin C. It was long ago suspected that the 
feeding of sterilized milk, condensed milk and preserved propri- 
etary foods was responsible for the majority of cases of scurvy. 
Even recent investigations into this subject trace the immediate 
cause to the use of pasteurized milk or foods prepared with 
boiled milk (Hess and Pish, Amer. Jour. Dis. Child., Dec, 



DIATHETIC AND CONSTITUTIONAL DISEASES 439 

1914). The two-fold heating of milk, that is, boiling or re- 
pasteurizing a pasteurized milk, is an important etiological 
factor. The early symptoms have been frequently controlled 
by simply substituting raw milk for pasteurized milk. The 
exclusive use of patent foods is a notorious cause for scurvy, 
as was shown by the American Pediatrics Society's investigation 
in 1898. 

Notwithstanding the undeniable relationship between scurvy 
and milk that has been subjected to a high temperature, never- 
theless, other factors appear necessary in the etiology of the 
disease for by no means all infants thus fed become scorbutic. 
I have seen several cases of scurvy develop in infants who were 
fed with raw milk, but the cows from whom this milk came 
probably did not receive any fresh, green fodder. On the other 
hand, in some communities it has long been the custom to feed 
infants with boiled milk and yet scurvy rarely develops there. 
This applies especially to mild and warm climates, where, 
incidentally, rickets is also less common than in the colder 
climates. Perhaps the early resort to mixt feeding in these 
countries and the transmission of vitamines through the pla- 
cental blood in sufficient amount to ward off scurvy explains 
these apparent discrepancies. ~No doubt the mother's diet 
during pregnancy has some influence on the etiology. Accord- 
ing to the observations of Hess, there is a strong relationship 
between the exudative diathesis and scurvy, although there is 
no direct relationship to rickets. 

Age is an important predisposing factor. The majority of 
cases are encountered during the second half of the first year. 
It is rare before the sixth month or after the eighteenth month. 

Symptoms. — The characteristic symptoms of scurvy in 
infancy are anemia; sponginess and bleeding of the gums; 
subperiosteal hemorrhages notably of the lower extremities; 
general sensitiveness of the body, and pseudo-paralysis of the 
extremities. 

The early manifestations of scurvy are a moderate amount 



440 DISEASES OF CHILDREN 

of fever and painfulness of the extremities, most marked about 
the epiphysis of the bones. The child often shows the early 
symptoms of rickets, as an associated manifestation of faulty 
hygiene and feeding. A failure to gain weight and a standstill 
in the child's growth as a rule precede the appearance of the 
hemorrhagic manifestations. Anorexia is a frequent early 
symptom and when this is noted in a child that is fretful, pale, 
not gaining in weight and loath to be handled, we have a 
symptom complex which is strongly suspicious of beginning 
scurvy. 

Associated with the hypersensitiveness of the extremities we 
may soon detect a swollen, purplish appearance of the gums and 
perhaps small petechial spots on the body. As the disease 
progresses a distinct swelling can be made out in one of the 
extremities. The most frequent site for the swellings, which are 
due to sub-periosteal hemorrhage, is the lower extremity of the 
femur. Both legs may be involved. The frequent handling 
of the legs in changing the diaper may be responsible for the 
hemorrhage. Another favorable site for the sub-periosteal 
hemorrhage is the lower end of the tibia. The epiphysis may 
be involved to a degree resulting in epiphyseal separation. 
Epiphyseal hemorrhage is an early symptom and may be recog- 
nized by the X-ray as the "white line" of Frankel. 

Hematuria is at times the first symptom observed, and to- 
gether with tenderness of the body may be the only symptom 
present. Morse has reported several such cases, and Barlow 
himself recognized this fact at the time he brought the disease 
before the notice of the profession. 

The course of scurvy is an acute one, and under proper 
treatment it can be shortened to a few weeks. Fatal 
cases have occurred, especially in those whose true nature was 
not recognized in time. While the acute manifestations of the 
disease promptly subside upon the institution of antiscorbutic 
treatment, still it may require weeks and even months before 
a large, organized sub-periosteal clot is completely absorbed. 



DIATHETIC AND CONSTITUTIONAL DISEASES 441 

The diagnosis is not difficult when the characteristic symp- 
toms have developed. Hematuria in infancy should always 
be looked upon as strong presumptive evidence of scurvy, 
and the application of the therapeutic test, namely, fresh milk 
and orange juice, should be employed in such cases. 

Syphilitic epiphysitis occurs in younger infants, usually from 
two to four months old; it involves, by preference, the lower 
end of the radius or is multiple and symmetrical and is asso- 
ciated with snuffles and skin and mucous membrane lesions. 

Articular rheumatism is more frequently diagnosed in cases 
of scurvy than any other condition. Such a diagnosis indicates 
carelessness on the part of the physician, for there is no arthritis 
in scurvy but a lesion of the shaft of the bone at the epiphysis 
and above the same. Furthermore, articular rheumatism is 
practically unknown in infancy. An arthritis in infancy is, as 
a rule, septic or gonococcic in origin. 

Treatment. — In the treatment of scurvy a change of food 
is demanded at once. A milk formula suitable to the child's 
age, preferably unsterilized, and fed in definite quantity and 
at regular intervals, together with the administration of fruit- 
juice (three to four teaspoonfuls of orange-juice twice daily), 
are the prime dietetic requirements. Other valuable additions 
to the diet are potato, tomato juice and green vegetables. In 
the case of young infants a small amount of baked potato may be 
mixed with the milk while in older infants it may be given as 
a vegetable. Fresh meat-juice should also be given at regular 
intervals if anemia and prostration are marked. 

Constitutional remedies are of value, particularly for the 
malnutrition. The child's suffering can also be alleviated by 
remedies covering the acute symptoms such as ferrum phos., 
oryonid, rhus tox., ruta and mercurius. 

As a constitutional remedy phosphorus should be prescribed. 
This remedy covers the pathological changes encountered both 
in the blood and in the osseous system. 



442 DISEASES OF CHILDREN 

EXUDATIVE DIATHESIS. 

The term exudative diathesis was coined by Czerny to indi- 
cate an abnormal type of constitution in consequence of which 
the infant becomes susceptible to various skin and mucous 
membrane affections characterized by exudation and inflam- 
matory reactions. The skin presents a predisposition to scal- 
ing, erythema, papular lesions (lichen strophulus) and eczema. 
The scalp is affected with seborrhea while on the face a moist 
type of eczema develops. Wherever the skin is thrown into 
folds, about the neck and buttocks especially, a severe type of 
intertrigo develops. 

The mucous membranes are prone to catarrhal inflammation 
and rhinitis and recurring bronchitis are common symptoms. 
Lingua geographica is observed at times. Dyspeptic disturb- 
ances with mucus in the stools is a common occurrence. There 
is also a tendency to swelling of the superficial lymph nodes 
while the tonsils and pharyngeal adenoid tissue are usually 
hyperplastic. 

Infants presenting symptoms of exudative diathesis are usu- 
ally plump and well nourished in appearance suggesting a 
case of overfeeding. They are susceptible to infections and 
frequently a moderate degree of irregular continued fever is 
noted, suggesting a tubercular infection. The temperature, 
however, is due to a dyspeptic condition or a naso-pharyngeal 
affection and a negative von Pirquet reaction as well as the 
subsequent course of the case serve to exclude tuberculosis. 
Occasionally an infant showing the clinical manifestations of 
the exudative diathesis will be thin and undernourished but 
as a rule they are fat. 

The blood shows an eosinophilia which is the most charac- 
teristic and suggestive clinical manifestation of the condition. 
This would indicate that the child is suffering from a chronic 
protein sensitization resulting from an intolerance to cow's 
milk or to overfeeding with the same. The fact that an infant 



DIATHETIC AND CONSTITUTIONAL DISEASES 443 

with symptoms of the exudative diathesis promptly improves 
when the diet is changed from milk to cereals and vegetables 
tends to confirm the belief that it is a condition of intolerance 
to the protein of cow's milk. Similar symptoms may develop 
in a breast-fed infant as a result of overfeeding plus infection, 
the anaphylaxis being of bacterial origin as in some cases of 
bronchial asthma or the sensitization may occur through the 
breast milk from certain foods in the mother's diet (O'Keefe). 
The first step in the treatment of manifestations of the 
exudative diathesis is to cut down the amount of food, reduc- 
ing the feedings to four to five daily and substituting cereals, 
vegetable soup and strained vegetables for one or two of the 
milk feedings. It is also well to skim the milk; two to three 
teaspoonfuls of cod liver oil each day can be substituted for the 
cream. Buttermilk in place of sweet milk may also be given 
at times with good results. 

SPASMOPHILIA; TETANY. 

Spasmophilia, or the spasmophilic diathesis is a condition 
of abnormal mechanical and electrical irritability of the peri- 
pheral nerves associated with a tendency to localized and gen- 
eral convulsions. It is frequently encountered in infancy both 
in a latent and active form and there is a distinct seasonal 
occurrence during the colder months of the year. It is prac- 
tically never encountered in breast-fed infants. Etiologically 
it is a disturbance of calcium metabolism resulting from a diet- 
etic error or from inability of the infant to adjust itself to 
cow's milk together with a deficiency of fresh air and sunshine 
as its seasonal incidence suggests. Evidences of rickets are 
frequently associated with spasmophilia. 

The majority of convulsions occurring in infants are due to 
spasmophilia. Attacks of spasm of the glottis, rotary head 
spasm and tetany are also manifestations of spasmophilia. 
Striated muscles alone are affected; the spasmodic symptoms 
encountered in the "hypertonic infant" which involve the 



444 DISEASES OF CHILDREN 

gastrointestinal tract to a large extent producing pylorospasm 
and intestinal colic are manifestations of vagotonia and not 
of spasmophilia. 

The most constant symptom of spasmophilia is the height- 
ened electrical irritability of certain motor nerves (Erb's phe- 
nomenon). This is elicited by placing one electrode over the 
chest or abdomen and the other over the median nerve in the 
bend of the elbow. The peroneus nerve may also be used in 
making this test. In a normal infant the cathodal opening 
contraction is brought about with a current of 5 milliamperes 
while in spasmophilia 3 to 4 milliamperes will produce a sharp 
contraction. 

The mechanical irritability of the peripheral nerves is demon- 
strated by striking the nerve or one of its branches a quick 
blow with a percussion hammer or with the finger; contraction 
of the muscles supplied by the nerve results from this stimulus. 
The most characteristic response is seen when the facial nerve 
is irritated by a light blow on the cheek, this being followed 
by a quick contraction of the face muscles (Chvostek's sign). 

Another diagnostic sign of spasmophilia is Trousseau's phe- 
nomenon which is the production of a tonic spasm of the 
muscles of the hand and forearm in the position seen in tetany 
by compression of the nerves and bloodvessels in the bicipital 
groove. There is some danger, however, of bringing on an 
attack of laryngospasm in eliciting this phenomenon and so 
caution should be exercised in making use of this diagnostic 
sign. 

The chief clinical manifestations are general convulsions, 
spasm of the glottis and tetany. 

General convulsions, or infantile eclampsia are attacks of 
epileptiform convulsions with clonic spasms of the entire skele- 
tal muscular system associated with loss of consciousness. The 
convulsive manifestations usually last for several minutes and 
there is a strong tendency for the same to recur. The age of 
the patient, the tendency to repetition of the attacks and the 



DIATHETIC AND CONSTITUTIONAL DISEASES 445 

presence of the stigmata of spasmophilia serve to differentiate 
infantile eclampsia from epilepsy. The convulsions are usu- 
ally precipitated by some source of local irritation such as a 
gastrointestinal upset or teething; the onset of an acute infec- 
tion is also liable to be ushered in with a convulsion. 

Often, however, the convulsions cannot be assigned to any 
demonstrable cause. They may recur at frequent intervals or 
occur only once as the result of an acute digestive disturbance 
or fever. While convulsions are always alarming and cause 
the parents the greatest concern, still they rarely prove fatal 
in themselves and are not as dangerous to life as spasm of the 
glottis. When convulsions continue uninterruptedly, however, 
assuming the status epilepticus the condition becomes grave. 
Death from uncomplicated convulsions is rare. A child may 
apparently die from a convulsion but an autopsy will demon- 
strate the status lymphaticus, meningitis, or a severe infection 
(streptococcic or pneumococcic). 

Spasm of the glottis, or laryngospasm is mainly observed in 
rachitic infants; it is rarely observed in children over two 
years old. The symptoms of laryngospasm are a sudden cessa- 
tion of respiration accompanied by ineffectual efforts to inspire 
and symptoms of asphyxia. The child may lose consciousness 
and become limp and near death. At this stage it may die or 
the spasm relaxes, inspiration accompanied by a crowing sound 
occurs and consciousness returns. In fatal cases death is usu- 
ally attributed to cardiac paralysis rather than to asphyxia 
(heart tetany). It is a question, however, whether the heart is 
directly affected by the spasmophilic condition. The most 
plausible explanation attributes the infant's death in these cases 
to an expiratory apnea. Mild forms of laryngospasm are also 
encountered which manifest themselves as a crowing respiration 
noted whenever the child becomes excited or cries. While 
this condition is of no importance in itself, still notice should 
be taken thereof as it may be the forerunner of more serious 
symptoms. 



446 DISEASES OF CHILDREN 

Tetany, or carpopedal spasm is the most striking manifesta- 
tion of the spasmophilic diathesis and presents a nniqne clini- 
cal picture. There is a persistent contraction of the flexor 
muscles of the hands and feet fixing them in a characteristic 
position. The hands are flexed at the wrist, the fingers are 
extended and flexed at the metacarpal-phalangeal joint and held 
in firm apposition to the thumb, giving the hand the so-called 
"obstetrical position." The feet are extended and held as in 
talipes equinus with the toes flexed like the fingers. The spasm 
comes on suddenly involving first the fingers and wrists, after 
which the ankle-joints and toes become fixed. Older children 
may complain of numbness and tingling in the extremities 
preceding the attack. A cramp-like pain in the muscles may 
be complained of and attempts to overcome the contracture are 
evidently painful. The spasm may extend to other groups 
of muscles so that the extremities may become involved and 
opisthotonus develop. Strabismus is noted at times. When 
the facial muscles are involved the features assume a peculiar, 
fixed expression. The attack may only last a few hours or 
it may persist for several days at a time. Frequently the at- 
attacks are intermitting. 

Tetany is differentiated from tetanus by the absence of 
trismus, which is usually the first symptom of tetanus. It 
may be confused with cerebral diplegia or Little's disease but 
these are chronic affections of long standing with character- 
istic signs of upper neuron involvement and they do not pre- 
sent the characteristic carpopedal type of contracture seen in 
tetany or Chvostek's or Trousseau's signs. 

The prognosis for the ultimate disappearance of the mani- 
festations of spasmophilia is good if the child can receive the 
proper hygienic and dietetic treatment. Of first importance 
is abundance of fresh air and sunshine. There is a spontaneous 
improvement in all cases during the summer months undoubt- 
edly due to the outdoor life and sunshine which the infant 
naturally gets at this time of year. 



DIATHETIC AND CONSTITUTIONAL DISEASES 447 

In regard to diet, breast-milk gives the best results and may 
be looked upon as a specific. However, the difficulty of obtain- 
ing a wet nurse usually puts this method of feeding out of the 
question. Cow's milk may be continued in the case of young 
infants the daily quantity being limited to 16 to 20 ounces and 
part of the cream removed. Cereals and vegetables (strained 
vegetable soup) must be added to the diet as soon as possible, 
substituting a feeding with cereal or soup for one of the 
customary bottles. If the infant is constipated a malt soup 
formula should be used in place of a simple milk modification. 
Cod liver oil and phosphorus are the best therapeutic agents. 
Three to four teaspoonfuls of cod liver oil with a little orange 
juice may be given daily in conjunction with a drop of the 
homeopathic tincture of phosphorus three times daily. 

STATUS LYMPHATICUS AND ENLARGEMENT 
OP THE THYMUS GLAND. 

Enlargement of the thymus gland in infancy is looked upon 
as a clinical manifestation of the status lymphaticus although 
the condition is frequently encountered in the absence of any 
symptoms of the lymphatic diathesis. On the other hand, 
the typical case of the so-called status lymphaticus is one which 
has never shown symptoms of an enlarged thymus. Such an 
infant, in the midst of apparent health and with a negative past 
history, may suddenly develop a high temperature accompanied 
by convulsions and die within less than twenty-four 
hours. Another evidence of this diathesis is sudden death 
during an anesthetic or even sudden death without any discern- 
ible cause. The autopsy findings under these circumstances may 
confirm the suspicion of the status lymphaticus as the determin- 
ing cause of death. The pathological changes encountered are 
a universal hyperplasia of the lymphoid tissue throughout the 
body most strikingly seen in the enlargement of the bronchial 
glands, the mesenteric glands and the solitary follicles of the 
small intestines. There is enlargement of the spleen and hyper- 



448 DISEASES OF CHILDREN 

trophy of the tonsils. Sometimes lymphoid tissue is found in 
the various organs such as the liver and kidneys. The thymus 
gland is almost always found enlarged in these cases although 
there may have been no symptoms referable to the thymus 
during life. 

The thymus gland at birth is slightly larger than in later 
infancy and it undergoes a gradual involution so that at five 
years it weighs 4 grams as compared to 6.5 gms. at birth. 
According to Bovaird and Mcoll a thymus of 10 gms. and over 
may be considered abnormally large. Cases have been recorded 
in which the gland weighed from 30 to 40 gms.. In such 
instances the general lesions of status lymphaticus, namely, 
marked hyperplasia of the tracheobronchial lymphnodes and 
a general hyperplasia of the lymphoid structures throughout 
the body are usually encountered. An enlarged thymus can 
usually be palpated in the suprasternal notch. Prominence of 
the sternum may also be noted. 

Percussion of the normal thymus is not possible. Dulness 
in the region of the gland is evidence of hypertrophy of the 
same. The dimensions of the normal thymus are two to three 
centimetres in breadth and about five centimetres in length. 
The area of dulness over an enlarged thymus exceeds these 
dimensions considerably. 

The symptoms directly due to the enlarged thymus are 
dyspnea and a laryngeal stridor occurring either intermittently 
or more or less constantly present. In the milder cases the 
dyspnea is only noted when the child cries or becomes excited; 
in the more severe cases a constant difficulty in breathing is 
noted. The respiratory embarrassment may be so pronounced 
as to result in attacks of cyanosis. The dyspnea is inspiratory 
in character and is aggravated by moving the head backward. 

Another prominent symptom is a persistent cough occuring 
in a young infant without any demonstrable cause. It is dry 
and paroxysmal in character and may have been noted from 
birth. Sibilant rales may be heard in the chest, probably 



DIATHETIC AND CONSTITUTIONAL DISEASES 449 

resulting from pressure upon a bronchus or from irritation of 
the broncho-constrictor fibres of the vagus. In one of my cases 
the child died in one of its suffocative attacks and at autopsy 
the trachea was found flattened out by the pressure of an 
unusually large thymus. 

As a rule the symptoms of respiratory embarrassment and 
the cough are present from birth but at times these symptoms 
do not develop until a later period. A cold or an attack 
of bronchitis may first call attention to the condition and the 
persistence of the symptoms will arouse the suspicion of an 
enlarged thymus. 

The diagnosis of enlargement of the thymus gland in well 
marked cases should not be difficult. We should suspect the 
condition when the characteristic symptoms above enumerated 
are encountered, namely: 

1. Recurring attacks of dyspnea which cannot be attributed 
to adenoids or other nasopharyngeal obstructions, e.g. retro- 
pharyngeal abscess, the dyspnea being inspiratory and aggra- 
vated by hyperextension of the head. 

2. Persistent cough and stridor in a young infant, present 
since birth or developing later in infancy, with inspiratory 
dyspnea and without fever. The presence of fever and ex- 
piratory dyspnea suggest bronchial gland tuberculosis. 

The diagnosis can usually be verified by the following signs : 

1. Dulness over the upper portion of the sternum. 

2. Resistance in the suprasternal notch, increased during the 
expiratory phase. 

3. X-ray demonstration of an increased shadow to either 
side of the sternum, overlying the great vessels. 

Treatment. — The results obtained by the X-ray treatment 
of enlarged thymus gland are most encouraging. I have seen 
prompt and lasting improvement in the pressure symptoms in 
a number of cases treated in this manner. There is no doubt in 
my mind that the X-ray causes a decrease in the size of the 
30 



450 DISEASES OF CHILDREN 

gland judging from the relief of the symptoms following its 
employment. The technique is as follows: 

The child is treated every three weeks, three minute ex- 
posures being given both front and back with a Coolidge tube 
of 8% inch vacuum, used at a distance of 8 inches, the rays 
being filtered through 3 millimeters of aluminum (Dr. J. W. 
Frank). Often improvement will be noted after the first 
treatment. 

Surgical interference may become necessary when the pres- 
sure symptoms become alarming. Intubation or tracheotomy 
are valueless because the tube does not reach far enough down 
into the trachea. Partial resection of the gland, or anchoring 
the gland to the upper portion of the sternum has given relief. 

Constitutional treatment should be carried out in conjunc- 
tion with the X-ray or surgical treatment. The associated 
bronchitis usually requires attention and belladonna will relieve 
the cough and wheezing. The lime salts are valuable especi- 
ally since the thymus is so prominently associated with calcium 
metabolism. A 3x trituration of the iodide of lime is the pre- 
ferable form in which to use this salt. Cod liver oil should 
be given in conjunction with the calcarea iodide because of its 
beneficial effect on calcium metabolism. 



TUBERCULOSIS. 

Tuberculosis in infancy and childhood is usually encountered 
in the primary stage of the infection. In infants there is a 
tendency to a rapid spread of the process to contiguous struc- 
tures owing to the infant's lack of resistance to tuberculosis and 
therefore the evidences of a secondary infection are soon demon- 
strable. In older children the infection is, however, usually 
held in check by the regional lymph-nodes and a secondary 
invasion of the lungs or a general infection is thereby prevented. 
For this reason tuberculosis in infancy presents a high mortality 
rate because of the infant's lack of resistance to the infection 



DIATHETIC AND CONSTITUTIONAL DISEASES 451 

while in childhood the mortality is low and the disease tends 
to become localized and remain latent. 

On the basis of these observations it is generally held, in 
reference to the etiology of pulmonary tuberculosis, or consump- 
tion, that the seed for the same is sown in early childhood and 
that the pathological changes which occur in the lungs in a 
case of consumption do not correspond to the pathology of a 
primary lung infection but represent the reaction of a partially 
immunized individual to subsequent infections. 

There is probably no natural immunity against tuberculosis. 
Infants appear to be particularly susceptible to the tubercle 
bacillus and evidently exposure to infection is all that is re- 
quired in order to contract the disease. Arrested infections, 
however, acquired during early childhood, appear to confer 
more or less immunity against subsequent infections in later 
life. Such an infection at least tends to develop resistance 
against the spread of the disease throughout the body and 
thereby lessens the chances for the development of acute mil- 
iary tuberculosis or tuberculous bronchopneumonia. This as- 
sumption is based upon the fact that tuberculosis is usually of 
the disseminated type in infancy while during later childhood 
it tends to become localized. In this localized, or glandular 
form it may become dormant and eventually undergo spon- 
taneous cure. If, however, a child with such a latent infection 
is re-infected or its vitality is depressed by an intercurrent dis- 
ease or through improper food and unhygienic surroundings, 
a new tubercular process, modified by the partial systemic im- 
munity toward the tubercle bacillus, develops. Such a process 
does not present the manifestations of an acute miliary or 
caseous tuberculosis but it is characterized by a chronic course 
and shows attempts, more or less successful, on the part of the 
host to overcome the infection (see " Tuberculosis of the 
Lungs"). 

Childhood furnishes the majority of cases of localized tuber- 
culosis, namely, tuberculosis of the glands, bones and joints. 



452 DISEASES OF CHILDEEN 

The scrofulous child is one that has a latent infection, usually 
glandular, which more or less protects it against a general in- 
fection, but which has made it hypersensitive to the toxin of the 
tubercle bacillus. These children develop severe reactions on 
the mucous membranes and skin and give a strong von Pirquet 
reaction. They are also liable to phlyctenular keratitis. The 
majority of children over two years of age who develop tuber- 
culous meningitis and acute general tuberculosis show no evi- 
dence of previous infection. They do not give the von Pirquet 
reaction and at the autopsy there is rarely evidence of an old 
lesion. In children under two years of age however tubercu- 
lous meningitis and acute miliary tuberculosis occur as the 
so-called second stage of tuberculosis and develop as the result 
of a primary lung focus which the young organism is unable 
to hold in check. Infants appear to be unable to develop any 
degree of immunity against tuberculosis such as older children 
acquire from a small focus. The lymph nodes may hold up 
the infection for a while but as a rule it soon passes this bar- 
rier and extends into the pulmonary structure or gains entrance 
into the circulation setting up a generalized infection. 

The percentage of latent tuberculosis among children of 
apparently normal health is strikingly high. Before the dis- 
covery of the cutaneous tuberculin test we could only surmise 
but not prove that a child harbored the tubercle bacillus some- 
where in its body. This was the only explanation for the sud- 
den development of active tuberculosis in a child previously 
apparently healthy after an attack of measles or whooping- 
cough or a rapid breakdown during adolescence incident to un- 
hygienic surroundings, overwork at school, or in factories, 
insufficient food, etc. 

In 1907 von Pirquet announced his cutaneous tuberculin 
test to the profession as a safe and practical method of demon- 
strating the presence of tuberculous infection in the individual 
reacting to this test. The fact that the reaction may be present 
even some time after the lesion has healed, owing to the pres- 



DIATHETIC AND CONSTITUTIONAL DISEASES 453 

ence of immune bodies in the tissues, makes the test of ques- 
tionable value in adults but does not lessen its usefulness in 
childhood. 

Von Pirquet found that in a series of 1,134 children in 
Vienna, clinically non-tuberculous, the reaction was found in 
percentages which rapidly rose, almost with step-like regularity, 
from 15 per cent at two years to 90 per cent at fourteen years. 
Mortality figures in tuberculosis strangely contrast with these 
findings. Death from tuberculosis in childhood is highest in 
early infancy. This is due to the infant's close proximity to the 
parent or nurse who may have tuberculosis and its close con- 
finement to the house. Also to the fact that infection at this 
stage tends rapidly to become general. 

The mortality falls decidedly after the third year and the 
lowest figures are reached between the fifth and tenth years. 
It does not materially rise again until the time of puberty at 
which epoch phthisis becomes a common disease. 

How does the child become tuberculous? All signs point to 
infection by the way of the respiratory route, the source being 
an individual with open tuberculosis. Other forms of infection 
occur but they are rare. Of these, infection through the ali- 
mentary tract is of first importance. Primary intestinal tuber- 
culosis is far less common than primary pulmonary infection, 
the chief reason, perhaps, being that it requires an enormously 
larger number of bacilli to set up an infection when the bacilli 
enter by the way of the alimentary tract than when they are 
inhaled, this has been proven by animal experiments. No 
doubt the same condition holds good in the case of human 
beings. The milk supply evidently plays an important role in 
the etiology of intestinal tuberculosis and the bovine type of 
bacillus has been identified in such cases. 

Infection may take place through the mouth and tonsils and 
this explains the mode of occurrence of cervical and sub-maxil- 
lary tuberculous adenitis . In cases showing involvement of the 
supra-clavicular glands there is an associated apical pleurisy. 



454 DISEASES OP CHILDREN 

The bronchial glands, however, are the site of the infection 
in the great majority of cases irrespective of whether the child 
is clinically tuberculous or not. Most pathologists are of the 
opinion that the changes in the bronchial glands are secondary 
to a focus in the lung. This could not well be otherwise judg- 
ing from the course pursued by an infection with the tubercle 
bacillus in other regions of the body. 

Since the bronchial glands show the most advanced changes 
in the majority of autopsies, a belief in the preponderance of 
respiratory infection is justified. When the chain of glands on 
the right side is involved a primary focus can be found in the 
right lung and vice versa. Infection of both chains can only 
occur when there is a primary lesion in both lungs. 

Bronchial gland tuberculosis is, therefore, the most impor- 
tant clinical variety of tuberculosis in childhood. If such an 
infection is latent it can only be suspected from the presence of 
a positive von Pirquet reaction. Enlarged bronchial glands 
may, however, frequently be demonstrated by percussion and 
auscultation, according to the method of d'Espine. 

The sign to which d'Espine called attention is dulness 
between the shoulder blades, most marked from the 2d to the 
4th dorsal vertebrse, associated with exaggerated transmissions 
of the whispered voice over this area. If the child is made 
to speak in a low voice an accompanying whispering sound is 
heard. The respirations are also distinctly bronchial over this 
area. The bifurcation of the trachea is on a line with the 3d 
dorsal spine and here the main bronchial glands are situated. 

Enlarged bronchial glands may also produce obvious symp- 
toms, the recognition of which makes the diagnosis possible 
independent of physical diagnosis and the cutaneous reaction. 
The symptoms referred to are a high pitched metallic cough, 
associated with expiratory dyspnea. This syndrome is seen 
typically only in infancy, at which age the presence of tuber- 
culides is also a frequent aid in the diagnosis of tuberculosis. 
Tuberculides are small, hard papules, about the size of a pin 



DIATHETIC AND CONSTITUTIONAL DISEASES 455 

head, bearing a central depression. They are scant and may- 
be found upon the trunk and extremities. Their clinical 
importance was first pointed out by Hamburger, one of Pir- 
quet's associates. 

Owing to the great prevalence of latent tuberculosis in 
childhood we should always bear it in mind in the presence of 
obscure fevers and in all cases of malnutrition and anemia. 
The mistake, however, is often made of ascribing to tuberculosis 
recurring or continued fevers due to a focal infection, empyema, 
rheumatism and intestinal toxemia. 

The symptoms of tuberculosis in childhood depend upon 
the stage of the infection and the severity of the same. In the 
primary stage there is usually a continued irregular fever, 
loss of weight and anemia. These symptoms are more marked 
in infants than in older children. At this age the infection 
tends to spread rapidly to adjacent tissues and tuberculous 
bronchopneumonia or caseous pneumonia frequently develop 
within a short time after the bronchial glands have been 
infected. In older children, however, the primary infection 
is usually held in check by the lymph-nodes. There is, there- 
fore, less danger of a general infection and the child may show 
no characteristic clinical manifestations which would suggest 
tuberculosis. A child with infected lymph-nodes, however, is 
likely to present a slight evening rise of temperature and show 
some evidence of malnutrition and anemia. A positive von 
Pirquet reaction and the d'Espine sign can usually be dem- 
onstrated. The tuberculous child is characteristically of slight 
build and is mentally alert; the skin is of fine texture and 
transparent and there is a tendency to excessive growth of hair 
between the shoulder blades and over the shoulders. There 
is usually a positive tubercular family history in such cases and 
an evident hereditary predisposition to pulmonary tuberculosis. 
Another physical feature of these cases which no doubt predis- 
poses them to phthisis is the long, narrow, flat chest and the 
abdominal ptosis. 



456 DISEASES OF CHILDREN 

Acute miliary tuberculosis develops most frequently in in- 
fants as a result of general infection from a primary focus in 
the lung and bronchial glands. It is characterized by a high, 
continued fever of irregular type with rapid emaciation and 
the predominance of either respiratory or nervous symptoms 
according to whether the lungs or meninges are chiefly involved. 

Scrofula is a chronic form of tuberculosis in which there is 
a tendency for the process to remain localized in the lymphatic 
glands or bones. The scrofulous child is coarse featured, not 
as bright mentally as the tuberculous type and it is predis- 
posed to chronic skin and catarrhal affections (Exudative 
Diathesis). The prognosis as to life is much better in this type 
of tuberculosis which usually affects the lymphatic glands, 
particularly the cervical group, than in the type with a primary 
pulmonary infection. It is true, the bronchial glands arrest 
the infection in many instances but there is always the danger 
of this defensive barrier breaking down or of subsequent infec- 
tions occurring with the consequent development of the chronic 
form of pulmonary tuberculosis. 

Tuberculous Adenitis. — Tuberculous adenitis is distin- 
guished from simple adenitis by its chronic course and clinically 
by its predilection for involving the anterior cervical lymph 
nodes. It is rare in infants, in whom acute simple adenitis is, 
however, not uncommon. Tuberculous adenitis is most fre- 
quently encountered during the ages of from three to ten years 
and it is usually primary in nature, infection occurring by way 
of the tonsils and resulting from exposure to an individual with 
open tuberculosis or from drinking milk from a tuberculous 
cow. There is no doubt about milk infection being a frequent 
cause as the bovine type of bacillus has repeatedly been demon- 
strated in these glands. The child may also infect itself if it has 
a pulmonary tuberculosis ; in such cases the adenitis is a second- 
ary condition due to infection of the glands from sputum which 
is coughed up and which brings the tubercle bacilli in contact 
with the tonsils whence they are carried into the cervical 
lymph nodes. 



DIATHETIC AND CONSTITUTIONAL DISEASES 457 

Tuberculous cervical adenitis is usually unilateral and begins 
as a slowly increasing enlargement of one or more lymph-nodes 
which at first are painless and attract little attention. The gland 
gradually becomes larger and the swelling shows periods of 
exacerbation during which it may become sensitive. If the 
process continues the overlying skin eventually reddens, the 
gland which at first was firm and elastic in feel shows evidence 
of softening and breaks down. Spontaneous rupture takes 
place in due time with the formation of a sinus with ragged 
edges, infection of the skin and surrounding tissues and slow 
healing, leaving an unsightly scar. 

A single gland may be affected but more frequently there are 
a number of glands involved at the same time. In the early 
stages the glands remain discreet and they are freely movable 
while the overlying skin remains loose and unattached to the 
glands. In the later stages, however, the glands tend to fuse, 
forming a hard, nodular mass to which the overlying skin 
becomes attached. When such a mass breaks down several 
points of softening can be detected as a rule and a single 
opening does not suffice to satisfactorily drain the mass. The 
course of tuberculous adenitis is chronic, usually extending 
over a period of months and sometimes years. Resolution may 
occur, but the chances are against such an outcome, unless early 
treatment is instituted. 

The treatment of tuberculous adenitis is first of all the 
removal of diseased tonsils or teeth in order to stop any further 
re-infection of the glands in question. Constitutional treatment 
is also important, fresh air and cod liver oil being especially 
useful. The seashore is usually of more benefit than the 
mountains. In the early stages calcarea carb. is the most 
useful remedy. Mercurius and hepar sulph. are better indi- 
cated in simple acute adenitis. Some cases especially those of a 
very sluggish type appear to be benefited by tuberculin in 
potency. 

X-ray treatment has given excellent results in many of my 



458 DISEASES OF CHILDREN 

cases and should be tried whenever the case is seen early. As 
soon as signs of break-down appear the gland should be opened, 
all necrotic tissue removed and the wound packed with iodo- 
form gauze and allowed to heal by granulation. The radical 
removal of tuberculous glands is advocated by some surgeons 
but while this procedure undoubtedly gives excellent results 
in selected cases, nevertheless the more conservative method 
of waiting for signs of necrosis and then promptly draining the 
gland is the best routine method to adopt. The treatment of 
the other clinical forms of tuberculosis is discussed under their 
proper headings. 

HEREDITARY SYPHILIS. 

Syphilis in childhood is almost invariably an inherited dis- 
ease, although it may be acquired during parturition from a 
primary lesion of the vulva or from subsequent exposure to 
infection. This is usually the case when the mother acquires 
syphilis late in pregnancy, for if the disease is acquired after 
the eighth month the child escapes direct placental infection. 
Infection of the fetus takes place through the placenta. There 
is probably no direct transmission of syphilis from the father 
to the ovum as was formerly supposed, but the mother is in- 
fected primarily whether she shows clinical evidence of syphilis 
or not, and the spirochete are first carried from the maternal 
blood to the placenta. As a result of the infection of the pla- 
centa its blood vessels become diseased and the spirochete gain 
entrance into the circulation of the fetus. Fetal syphilis is, 
therefore, primarily a general blood infection and the newborn 
may present no characteristic anatomical lesions. The spi- 
rochete can however be demonstrated in the organs in such 
cases. 

Acquired syphilis differs from the above forms both in the 
manner in which the disease gains access into the system and 
in the presence of the primary sore, or chancre, which is never 
found in inherited syphilis. 



DIATHETIC AND CONSTITUTIONAL DISEASES 459 

The fetus has very little resistance to the invasion of the 
syphilitic virus for which reason the lesions eventually become 
very wide spread, and it does not possess the power of develop- 
ing anti-bodies so that the Wassermann reaction is usually 
absent in young infants. 

It was formerly held that mothers of syphilitic infants who 
did not present clinical evidence of syphilis were immune to 
the disease. Colles made the observation that such mothers 
could nurse their infected offspring without developing a pri- 
mary lesion of the nipple or subsequent indications of infection. 
This became known as "Colles' Law." The explanation of this 
apparent contradiction to the ordinary phenomenon of syphilis, 
lies in the fact that these mothers are syphilitic as proven by 
the large percentage of positive Wassermann reactions obtained 
from such women. 

Early or precocious hereditary syphilis may result in mis- 
carriage. Children showing active signs of syphilis at birth 
are seldom born alive. They may appear macerated, or the 
body be covered with an extensive bullous eruption. 

The variety of hereditary syphilis described as syphilis 
hereditaria tarda by Fournier, in which the appearance of spe- 
cific lesions is supposed to be delayed until after the third 
year of life, is not recognized by most syphilographers, it being 
held that the early manifestations in these cases were over- 
looked. Again, symptoms occurring in later childhood may be 
the result of an innocent infection (syphilis insontium). 

The pathological lesions of hereditary syphilis are well 
developed in most of the internal organs. The lungs show an 
increase in the interalveolar connective tissue and prolifera- 
tion of the alveolar epithelium (pneumonia alba). The liver 
may be enlarged as a result of round-cell infiltration of the 
inter-acinous spaces and pericellular cirrhosis; there may be 
gummata (rare) or simple interstitial connective tissue pro- 
liferation. These changes begin in the periportal region and 
spread into the acini, invading them with new connective tissue 



460 DISEASES OF CHILDREN 

and blood-vessels. The spleen is enlarged as a result of diffuse 
cellular infiltration of its interstitial tissue. 

In the bones, epiphysitis is a characteristic change already 
observed in the fetus. Other conditions will be referred to 
under the clinical manifestations of the disease. 

Symptoms. — The classical manifestations of syphilis which 
develop after birth are palmo-plantar pemphigus, coryza, cu- 
taneous syphilides, epiphysitis and cachexia. These symptoms 
develop in the order named, and it is important from the stand- 
point of diagnosis and treatment to have a proper understand- 
ing of the evolution of the disease. 

Pemphigus may develop in the fetus during the sixth or 
seventh month. It is, therefore, usually present at birth and 
represents the earliest clinical manifestation of syphilis. The 
lesions consist of bullae about one centimeter in diameter, situ- 
ated upon the palms of the hands and soles of the feet. The 
epidermis is loosened from the true skin and has a bleached 
macerated appearance. While the bullae are intact they con- 
tain a yellowish fluid. The bullae soon dry up and the epidermis 
falls away, leaving a raw copper colored surface. 

Coryza is one of the most constant manifestations of syphilis. 
At times it is the only symptom present the child appearing 
to be in good health otherwise. 

The earliest manifestations are a serous nasal discharge 
which later becomes sero-purulent. The nose is obstructed and 
the infant's respirations become noisy and embarrassed. The 
discharge is irritating and leads to erosion of the skin about the 
nares and the mouth with the development of fissures in these 
localities. 

Cutaneous syphilides appear shortly after the coryza. They 
consist of pink, oval macules more or less general in distribu- 
tion. At the end of a few days they become copper colored 
and desquamate. Wherever these papules are exposed to mois- 
ture, especially about the buttocks and about the mouth their 
surface becomes macerated and they increase in size and be- 



DIATHETIC AND CONSTITUTIONAL DISEASES 461 

come converted into ulcers and fissures. In severe cases the 
infants are emaciated and present bullous lesions on the palms 
of the hands and the soles of the feet at birth. This is soon 
followed by the development of diffuse infiltration of the skin 
with a tendency to scale; pustules; ulcerating lesions of the 
mucous membranes. In less virulent cases there appear at the 
end of a few weeks macular syphilides on the lower portion 
of the abdomen and on the buttocks ; papules and pustules may 
coexist. The pustules are especially common upon the face 
and buttocks. They have a tendency to ulcerate deeply forming 
dark-colored crusts. The skin appears shrivelled, poorly nour- 
ished, and presents a brownish discoloration. Associated 
symptoms are hoarse, plaintive cry, mucous patches in the 
mouth, rhagades at the angles of the mouth, anal condylomata 
and gastro-enteric catarrh, inducing loose, green stools. The 
syphilitic child soon develops malnutrition and a severe sec- 
ondary anemia ; the face wears a characteristic old and anxious 
expression. The internal organs, as mentioned above, are the 
seat of diffuse interstitial hyperplasia of the connective tissue, 
with resulting degenerative changes in the parenchyma of the 
liver, lungs and digestive system. Enlarged spleen in an infant 
under three months old is strong presumptive evidence of 
syphilis. The visceral lesions are responsible for the malnu- 
trition and eventual death of the syphilitic infant, although it 
may die from a basilar meningitis. 

The later manifestations of syphilis, occurring in cases not 
so malignant from the outset, are those referable to the bones, 
teeth, organs of special sense and nervous system. 

In the osseous system epiphyseal osteochondritis and dactyl- 
itis may occur early in the disease. Osteochondritis develops 
at the epiphyses of the long bones and by interfering with the 
growth of the bone may lead to deformity. The symptoms of 
epiphysitis are acute and simulate arthritis. The child holds 
the limb as if paralyzed on account of the pain. The lower 
end of the humerus is most frequently involved. Dactylitis pre- 



462 DISEASES OF CHILDREN 

sents a characteristic fusiform swelling of the fingers also attack- 
ing the metacarpal and metatarsal bones. Ulceration often 
results with the destruction of the bone and integument. Osteo- 
periostitis of the tibia, resulting in rounding out of the tibial 
crest and curving of the shaft — the sabre-blade deformity — 
is very characteristic of hereditary syphilis. In rickets the 
sharp crest of the tibia remains unchanged, while deformities 
of the bone are most marked at its lower end. Cranial exostoses 
upon the frontal and parietal bones are also found in well- 
developed cases. 

The milk teeth are delayed and decay early; the permanent 
teeth present pathognomonic signs first described by Jonathan 
Hutchinson, for which reason they are known as Hutchinson's 
teeth. The upper central incisors are dwarfed and present a 
notch upon their cutting surface, while the other teeth are 
poorly developed. 

Two other conditions to which Hutchinson has given much 
prominence are interstitial keratitis and otorrhea. Chronic 
otorrhea or sudden deafness should always arouse a suspicion 
of syphilis. Interstitial keratitis is a frequent symptom of 
syphilis, developing at the time of puberty. 

Nasal deformity is a characteristic sign of hereditary syphilis 
as well as radiating linear scars at the angles of the mouth. 
The latter results from ulcerating mucous patches, while the 
former is due to diffuse gummatous rhinitis, with accompany- 
ing ozena. 

Gummatous infiltration of the brain and cord may lead to 
a variety of disturbances in the nervous system. Meningitis; 
epilepsy; dementia paralytica; tabes dorsalis and hydrocephalus 
are among the most important nervous affections that can be 
traced frequently to a syphilitic origin. 

The diagnosis of syphilis is not difficult in the presence of 
a clear family history and clean-cut consecutive manifestations 
of the disease, but it may present difficulties when isolated 
symptoms are encountered. In the first place, a history of 



DIATHETIC AND CONSTITUTIONAL DISEASES 463 

miscarriages in the mother followed by the birth of a still-born 
infant or one that died of "inanition'' in early infancy is strong 
presumptive evidence of syphilis. Secondly, the presence of 
snuffles at birth is an important symptom. This, however, must 
not be confused with the innocent snuffles present at birth or 
due to adenoids. Specific snuffles begins in the second or third 
week and is associated with crust formation in the nose and 
often saddle nose. It gets progressively worse. Other sugges- 
tive symptoms are the malnutrition; the hoarse cry; enlarge- 
ment of the spleen ; mild grade of hydrocephalus ; buccal and 
anal ulceration and papulosquamous lesions in the palms of 
the hands and soles of the feet. A Wassermann reaction 
can usually be obtained in older infants but in the first weeks 
of life it is absent. The same can be said of Eoguchi's lutein 
skin reaction. Many cases of congenital debility and hemor- 
rhagic disease of the newborn are presumably syphilitic because 
a positive Wassermann reaction can be obtained in the mother 
although absent in the infant. 

The later manifestations of syphilis are all characteristic, 
and in the presence of such symptoms as Hutchinson's teeth; 
radiating linear scars; flattened nose-bridge; dactylitis and 
interstitial keratitis there should be no doubt of the diagnosis. 
The Wassermann reaction is as reliable at this age as in adults. 

Prognosis. — The death rate among syphilitic infants is high 
and the prognosis depends upon the severity of the early 
manifestations to a great extent. When symptoms are dis- 
covered at birth or shortly after, the infant usually succumbs 
because of the presence of an extensive general infection with 
very little natural resistance. When the early symptoms are 
mild and their appearance is delayed, the outlook is better. 
If an infant is well nourished at birth and can be nursed by 
its mother there is always a chance of eradicating the disease 
with proper treatment. A bottle-fed infant, however, has a 
decidedly poorer chance of recovery. The first born of a syph- 
ilitic parent usually presents the disease in a more serious form 
than the subsequent children, and is more likely to succumb. 



464 DISEASES OP CHILDEEN 

Treatment. — The syphilitic infant is a menace to its sur- 
roundings, for, with the exception of its mother, it is capable of 
infecting anyone with the disease. The lesions in the mouth 
and the discharges from the nose or from ulcerating papules 
or pustules anywhere upon the body are the sources from which 
infection may take place. 

Mercury is the best remedy with which to begin the treat- 
ment as it corresponds to the majority of the symptoms of 
secondary syphilis, the stage in which hereditary syphilis first 
manifests itself. The preparation from which I have obtained 
the best results is the protoiodide, in doses of two to three grains 
of the second decimal trituration four times daily. When the 
case is one of unusual severity with early appearance of active 
manifestations, the action of the mercury is more prompt and 
less likely to cause intestinal disturbances if given by inunction 
instead of by mouth. Ten grains of mercurial ointment, 
diluted with cold cream, should be rubbed into the abdomen, 
thighs or axilla daily until the symptoms have been brought 
under control. In the late manifestations of hereditary syphilis 
the iodide of potash must frequently be employed in material 
doses in conjunction with mercury. 

Cases which do not promptly respond to mercurial treatment, 
or in the more severe cases presenting such conditions as de- 
structive changes in the nasal septum, rapidly /progressing 
inanition, involvement of the eyes or of the nervous system, 
recourse should be had to the more quickly acting arsenical 
preparations. Neosalvarsan is the best one of these because it 
is least toxic and irritating and may be given intramuscularly 
in oil. The best results, however, are obtained by giving 
salvarsan intravenously. 

The superior longitudinal sinus has been used for the purpose 
of administering salvarsan intravenously to an infant. Helm- 
holz, of Chicago, in 1915 called attention to the clinical practic- 
ability of this route. Dunn and Howell, of Boston, successfully 
used the sinus for obtaining blood for the Wassermann reaction 



DIATHETIC AND CONSTITUTIONAL DISEASES 465 

and later gave salvarsan injections into the sinus. This pro- 
cedure is, however, not without danger and intravenous or 
intramuscular injections are, therefore, to be recommended. 

The dose of salvarsan is .05 grams for an infant one to three 
months old and 0.1 gram for three to six months. Holt allows 
0.01 gm. per kilogram of body weight. The dose of neosalvar- 
san is V/* times that of salvarsan. The injection may have 
to be repeated at the end of a week. 

As soon as the urgent symptoms have been controlled mer- 
curial treatment should be resumed. The Wassermann reaction 
may be employed in order to control the treatment, but it must 
be remembered that the reaction is often absent in syphilitic 
infants during the first month. 

The following remedies are mentioned in the homeopathic 
literature on the treatment of syphilis and should be consulted 
for special symptoms and conditions: 

Aurum. — Tertiary manifestations; exostoses on skull, tibia 
and bones of forearm; dactylitis w T ith ulceration; caries of 
nasal bones; defective development of genital organs; infantil- 
ism; mental depression. 

Kali bichromicum. — Snuffles; harsh voice and hoarse cry; 
deep ulcers on the edge of the tongue; ulcers on the velum 
palati eating through; ulceration of nasal septum (cartil- 
aginous portion) ; ulcers in general, with characteristic 
punched-out appearance. 

Kali hydro j. — Tertiary syphilis; diffuse and circumscribed 
gummatous infiltrations; mercurialization ; interstitial keratitis; 
otorrhea; swelling and ulcerative destruction of uvula. 

Mercurius. — The homeopathic relationship of mercury to 
certain stages of syphilis is a firmly established fact. An 
analysis of the cases successfully treated with mercury indi- 
cates that its most marked effects are the healing of ulcers 
and improvement in the general health, both of which belong 
to the truly homeopathic action of the drug (Hughes, Pharma- 
codynamics). Its "tonic" action is due to its hematic power, 
31 



466 DISEASES OF CHILDEElSr 

while its control over diffuse inflammation and swelling of the 
mucous membranes, accompanied by ulceration and inflamma- 
tions of serous membranes, periosteum and skin, depends upon 
its specific action upon these structures. This primary, specific 
action covers almost completely the early manifestations of 
hereditary syphilis, and the manifestations of mercurial poison- 
ing cover many of the destructive manifestations of the disease. 
Impetigo and rupia, rapid ulceration of the mucous membranes, 
skin and bones etc., strongly call for mercury, especially in 
combination with iodine, as recommended above or in larger 
doses when symptoms become urgent (inunctions). 

Nitric acid. — Deep, irregular ulcers on border of tongue, 
upon tonsils and soft palate; sticking pains in ulcers; rhagaded 
at angles of mouth; pustular and squamous syphilides; mer- 
curial stomatitis and cachexia; urine strong, ammoniacal; 
condylomata. 

Sulphur. — Syphilitic children often require an occasional 
dose of sulphur. The symptomatology of this remedy is too 
extensive to be considered here, its sphere of action embracing 
both general and special indications. Psorinum may likewise 
be called for occasionally. 

Thuja. — Flat, condylomatous lesions about the anus and 
ulcerating papules on the scrotum. 

RHEUMATISM. 

While rheumatism in the adult is usually seen as an acute 
polyarthritis of acute onset and limited duration, in childhood 
it presents the characteristics of a subacute generalized infec- 
tion with less tendency to affect the joints but with an almost 
universal one to attack the valves of the heart. The etiological 
relationship between the tonsils and rheumatism is much more 
clearly evident in children than in adults and in many cases 
the onset can be traced directly to an attack of tonsillitis. 
Rheumatism is rarely seen in children under four years of age. 

Acute arthritis, multiple in character and usually affecting 






DIATHETIC AND CONSTlTUTIOHAL DISEASES 467 

the smaller joints ; namely the wrists, ankles, and elbows, is the 
most striking and characteristic symptom of rheumatism. Arth- 
ritis of a single joint, particularly one of the larger joints, is, 
however, rarely due to rheumatism; sepsis or tuberculosis 
should always be suspected in such cases. The fingers are 
sometimes involved and this is indicative of a more severe 
type of rheumatic infection. 

Rheumatic nodules are an unusual manifestation of rheu- 
matism and they are found in a minority of cases as small oval 
fibrinous nodes situated along the tendons of the fingers, at the 
back of the elbow, about the knee joints and in other localities. 
While they are characteristic of rheumatism, still they are not 
found frequently enough to be of much diagnostic value. 

"Growing pains" are at times an indication of rheumatism 
and when a child complains of them it should be carefully 
examined for evidence of arthritis, muscular spasm and heart 
disease and the temperature should be taken regularly to deter- 
mine the presence of a slight continued fever. Frequently the 
so-called growing pains are only muscular soreness which comes 
from over-exertion or fatigue or the pains have resulted from 
a sprain. Torticollis is the most frequent form of acute rheu- 
matic myositis seen in childhood. 

Chorea is so frequently associated with rheumatic arthritis 
or with rheumatic heart disease that the relationship between it 
and rheumatism cannot be questioned. Chorea frequently fol- 
lows in the course of an arthritis and develops endocarditis 
as a complication. There is no doubt that in such cases the 
rheumatic toxin is the cause of the nervous symptoms. Chorea 
may develop independently of rheumatism but such cases are 
very likely toxic and may be more closely related to the rheu- 
matic cases than is apparent. 

Endocarditis is by far the most important and perhaps the 
most frequent complication of rheumatism in childhood. It 
is really a question whether we can call it a complication as it 
appears to be the primary manifestation of the infection in 



468 DISEASES OF CHILDREN 

many instances, ante-dating the occurrence of arthritis. It is 
an interesting clinical observation that cases with marked joint 
involvement often escape heart involvement while cases with 
endocarditis and pericarditis may present few if any joint 
symptoms. Endocarditis usually runs a subacute course and 
may become chronic; fever often persists for months. Even 
after the fever has subsided there is a strong tendency for 
relapses to occur. A leucocytosis is usually present while the 
fever persists. 

A number of shin manifestations have been observed associ- 
ated with rheumatic infection. They belong to the erythema 
and hemorrhagic group and present a multiplicity of clinical 
features. 

Diagnosis. — Symptoms resembling rheumatism occurring in 
a child under four years of age should always be investigated 
carefully before a diagnosis is made. Pains about a joint or a 
fixed joint do not necessarily mean an arthritis. The condi- 
tions most likely to be confused with arthritis are epiphysitis 
and infantile scurvy. 

Epiphysitis is a manifestation of congenital syphilis and 
other signs of syphilis are usually present. It is generally 
found in infants under six months old, affects by choice the 
epiphysis of the humerus causing a pseudo-paralysis of the arm 
with tenderness and slight swelling above the joint. The onset 
is slow and the course chronic. 

Infantile scurvy occurs in the latter part of the first year, 
affects principally the lower extremities and careful examina- 
tion reveals tenderness and swelling in the lower end of the 
long bones and not in joints. Swollen, bleeding gums are 
associated. 

Arthritis in infants is usually septic or gonorrheal; in the 
latter instance it complicates gonorrheal ophthalmia or vulvo- 
vaginitis. Aspiration of a joint reveals the presence of pus. 

Tubercular arthritis is of gradual onset, chronic in course 
and is usually monoarticular, involving one of the larger joints. 



DIATHETIC AND CONSTITUTIONAL DISEASES 469 

These are the hip, knee and shoulder, given in the order of their 
frequency. The cutaneous tuberculin test is usually positive 
and the X-ray shows evidence of bone destruction. 

A primary endocarditis should be considered rheumatic if 
any other cause for the same can be excluded. As a rule the 
history reveals a former attack of arthritis or chorea or these 
conditions develop after the endocarditis. 

Treatment. — The most important therapeutic measure in 
the treatment of rheumatism is prophylaxis. There is every 
reason to believe that our first duty to a child which presents 
rheumatic symptoms is to make a searching investigation for 
any evidence of a focal infection. Carious teeth and infected 
gums should receive immediate attention. Enlarged infected 
tonsils or small, buried tonsils with palpable sub-tonsillar nodes 
should be removed. The nose and post-nasal space should also 
receive attention as infected adenoid tissue or a sinus infection 
may be present. 

General hygienic measures which aim to increase the child's 
resistance to infection must be enforced. Woolen underwear 
in the winter is usually recommended but this may be objec- 
tionable in some cases. A carefully instituted hardening pro- 
cess, accustoming the child to sleep in the open air; avoiding 
over-heated apartments; cold sponge baths; strict attention to 
the digestion and bowels and a rest hour during the day are 
the most important general measures to be observed. Rheu- 
matic children should be strictly guarded from others with 
colds, sore throat and the infectious diseases. In a minor per- 
centage of cases removal to a warm, equable climate in winter 
may become necessary. The diet need not be restricted in nitro- 
genous food to the extent which is often done; there is no rela- 
tionship between meat or sugar in the diet and rheumatism as 
in the case of gout. The diet however should be a simple, nu- 
tritious, well-balanced one in which milk, butter, eggs, bread, 
cereals, green vegetables and fruit should play the most impor- 
tant role. During acute attacks a low diet is indicated. For 



470 DISEASES OF CHILDREN 

the anemia which is a result of rheumatic infection iron prepar- 
ations and cod liver oil are indicated. 

The remedies which are found useful for the general and 
arthritic symptoms in adults are of equal value in the child. 
When suffering is extreme the pain must be relieved. The 
snug wrapping of a joint in cotton or its complete immobiliza- 
tion often gives sufficient relief. Salicylates, however, may be 
necessary to allay the pain. Unfortunately they do not influ- 
ence the infection or prevent recurrences and complications; 
they are purely palliative. The average dose for a child is a 
iive grain powder of equal parts sodium salicylate and sodium 
bicarbonate given with plenty of water every three to four 
hours. 

Every case of rheumatic infection running a temperature, 
whether arthritic or choreic in type, should be kept in bed for 
observation until the temperature has remained normal for 
several days. Should any evidence of an endocarditis appear, 
rest in bed must be enforced until we can make certain, as far 
as that is possible, that the heart infection has subsided. To 
determine this point, the presence of fever and a leucocytosis 
are our chief guides. 



CHAPTER XVII. 

ACUTE INFECTIOUS DISEASES. 
EXANTHEMATA. 

The exanthemata constitute a group of acute infectious 
fevers usually occurring epidemically and characterized by 
the eruption of an exanthem upon the surface of the body. 
The group is composed of measles, rubella and scarlet fever. 
They are all contagious, but scarlet fever is less so than the 
others, perhaps because individual susceptibility to it is not 
as universal as with measles. Whether the exanthemata are 
due to bacteria or to a protozoon has not yet been determined. 

Space forbids reviewing the experimental work which has 
been done in order to determine the etiological factors in 
measles and scarlet fever. Suffice it to say that up to the 
present time the causative agent of neither of these contagious 
diseases has been isolated. It has been possible to transmit 
measles to monkeys by inoculations with the blood and nasal 
secretion of patients suffering from the disease. The contagium 
is a filterable virus which resists drying but is destroyed by a 
temperature of 55° C. In scarlet fever streptococci are per- 
sistently found in the throat and in the blood in the majority 
of severe and fatal cases; however the role of the streptococcus 
is more likely that of a secondary invader than an etiological 
factor. 

MEASLES, RUBEOLA. 

Measles is one of the commonest of the acute infectious 
diseases of childhood and there appears to be a universal suscep- 
tibility to it. A child that has been exposed to measles rarely 
escapes contracting the same. It occurs most commonly in 
epidemics during the months favoring catarrhal affections; 
spring epidemics are usually the severest. One attack affords 
immunity against another. The period of incubation is from 



472 DISEASES OF CHILDREN 

ten days to two weeks in the average case. Contagious- 
ness is present from the time of invasion, being most pro- 
nounced at the height of the catarrhal manifestations and 
fever. It rapidly vanishes with the disappearance of the erup- 
tion, and at the end of the third week there remains little or 
no danger of contagion. The contagion is usually spread by 
close contact, and is seldom conveyed by means of intermediate 
objects or a third person, it also being readily destroyed by 
thorough airing and fumigation. Measles, however, is more 
readily disseminated than scarlet fever or diphtheria, and an 
epidemic is more likely to attain wide-spread proportions than 
in those diseases. 

Symptoms. — The course of a typical case of measles is in 
three stages. These are characteristic of the exanthemata in 
general, but most clearly denned in measles. They are: the 
prodromal stage, the stage of eruption, and the stage of 
desquamation. 

The first stage is characterized by fever and catarrhal symp- 
toms of gradual onset. There are bloodshot eyes and lachry- 
mation, accompanied by chilliness and headache. The catarrhal 
process extends to the larynx and trachea, producing the 
characteristic hoarse cough. On the third day single, lentil- 
sized red spots are seen upon the roof of the mouth and soft 
palate, frequently being observed twenty-four hours before the 
eruption upon the skin makes its appearance. Koplik's sign 
appears even earlier and is more truly pathognomonic of 
measles in the period of invasion. Koplik describes this buccal 
enanthem as follows : "If we look into the mouth at this period 
we see in a strong light the usual redness of the fauces, perhaps 
not in all cases a few red spots on the soft palate. On the 
mucous membrane lining the cheeks and lips (buccal mucous 
membrane) we see a distinct and pathognomonic eruption. 
This consists of small irregular spots of bright-red color; in the 
centre of each spot is the interesting sign to which I wish to 
call attention. In strong daylight we see a most minute bluish- 



ACUTE INFECTIOUS DISEASES 



473 



white speck. These minute bluish-white specks in the centre 
of a reddish spot are absolutely pathognomonic of beginning 
measles. This sign is present in all cases twenty-four hours 
before the skin eruption, and often three days preceding it." 

The second stage begins on the fourth or fifth day. The 
eruption makes its appearance first on the face, the earliest spots 
occurring at the border of the scalp and behind the ears. 
Thence it spreads over the entire body surface, the eruption 
being completed in two to three days. Its spread, however, 
may be irregular and interrupted and desquamation may occur 
on one portion of the body while the eruption is appearing on 
another. The exanthem is the product of a superficial derma- 
titis, with papule formation, resulting from round-cell infiltra- 
tion about the papillae, the cutaneous glands and small blood 
vessels. There may also be edema of the skin accompanying 
the inflammatory process; this is most prominently seen upon 
the face. The eruption proper consists of numerous roundish, 
lentil-sized red spots, slightly raised above the level of the 
surrounding skin, or containing in their centre a little papule. 
Where they are very numerous they coalesce, forming crescentic 
plaques, or they may fuse into large, spotted areas. Cases in 
which the hyperemia is so great as to cause cutaneous hemor- 
rhages are described as petechial, or black measles; in these 
cases the eruption assumes a dark color from petechial hemor- 
rhages. Petechial measles is by no means always a more 
serious condition than the ordinary form; in fact, I have seen 
a number of cases running a rather mild course, in which the 
eruption assumed this hemorrhagic type. 

In young children convulsions sometimes occur at the time 
the eruption makes its appearance. The catarrhal symptoms 
reach their acme, and bronchopneumonia and troublesome 
diarrhea are to be feared during this period. Catarrhal inflam- 
mation of the conjunctiva, nose, pharynx, trachea and bronchi 
are so closely associated with the course of an attack of measles 
that they are really to be looked upon as characteristic lesions 



474 DISEASES OF CHILDREN 

of the disease. The strong tendency for the process to extend 
from the bronchi into the bronchioles and air vesicles is one of 
the most dangerous features of measles, and almost every 
fatal case is directly due to bronchopneumonia. 

The inflammation of the pharynx and larynx may become 
croupous, and suppurative otitis media may appear as a compli- 
cation at this stage, although neither of these conditions are 
as common in measles as in scarlet fever. 

In the alimentary tract a similar catarrhal condition may 
become established, showing itself as anorexia, vomiting, heavily 
coated tongue with enlarged marginal papilla^ and diarrhea. 
The latter, when once established, is liable to continue through- 
out convalescence. 

At the end of about four days the eruption begins to fade, 
disappearing first on those localities where it was primarily seen. 
In mild cases it has already become much paler at the end of 
twenty-four hours, and it may disappear entirely from one 
part while another part is being invaded. With the fading of 
the rash desquamation takes place in the nature of fine, branny 
scales, first noticed upon the face and neck. It is completed in 
a week in the average case, seldom continuing beyond this time. 

The eruptive period is prolonged in those cases in which it 
becomes hemorrhagic. Here it assumes a deep-red color, grad- 
ually becoming darker (ecchymotic) and slowly fading out as 
the blood-pigment is absorbed. Again, the eruption may 
suddenly disappear, indicating circulatory failure. 

The temperature is highest during the eruptive period, when 
it may reach 104° F. for two or three days. The average 
duration of fever is about a week. In a typical case there is 
an abrupt rise at the time of invasion — about 102.5° F. (initial 
fever). It soon falls to a lower point, gradually rising again 
until the fourth day, when the eruption makes its appearance. 
At this stage it may reach 104° F. and higher. It may drop 
by crisis on the fifth day or there may be a gradual decline so 
that normal is not reached until the seventh day. A longer 



ACUTE INFECTIOUS DISEASES 475 

febrile period or an accession of fever during the period when 
it should normally decline, indicates a complication. 

Among the many complications liable to arise during the 
course of measles or appear as sequelae, the following are the 
most important and most frequent; bronchopneumonia (child- 
ren under three years); pleuropneumonia and empyema (three 
years and over); membranous croup; putrid sore throat; noma; 
entero-colitis; conjunctivitis; keratitis; otitis media. 

The frequency with which tuberculosis develops after 
measles is noteworthy. In some instances latent scrofulous 
lesions are fanned into activity, while in others a primary 
pulmonary infection apparently occurs. The congestion of the 
bronchial glands which accompanies measles, renders them 
more liable to infection with the tubercle bacillus. According 
to Osier, tuberculosis is the most important sequela — either 
an involvement of the bronchial glands, a miliary tuberculosis, 
or a tuberculous bronchopneumonia. The observation that the 
von Pirquet cutaneous tuberculin reaction becomes negative 
during an attack of measles in children who have previously 
shown a positive reaction, would indicate that the defensive 
mechanism against tuberculosis is temporarily abolished by 
the infection. 

The blood in measles shows a mild degree of anemia and 
instead of a leucoeytosis there is a lymphocytic leucopenia in 
the early stages. This has also been observed during the incuba- 
tion period. The urine may give the diazo-reaction, but 
albuminuria is rare. 

Treatment. — The child should be put to bed in a well- 
ventilated room as soon as the disease is suspected, and a tem- 
perature of 65° F. maintained if possible. It is unnecessary 
to render the room dark and cheerless, but the eyes should be 
protected from direct bright light. The child should be kept 
in bed until every trace of the rash has disappeared, which 
usually takes a week. He should not be permitted to go out 
of doors until he has been up for a week, but during this time 



476 DISEASES OF CHILDREN 

he may be given a daily indoor airing, the windows being 
widely opened and the child clad as for outdoors. After sixteen 
days have elapsed from the time of onset of the disease, the 
quarantine may be lifted. 

The removal of the branny scales of epidermis is greatly 
facilitated by rubbing the child with olive oil, followed by 
sponging with tepid water and Castile soap. This measure 
should be employed for several evenings in succession after 
the febrile symptoms have abated. During the febrile period 
there is no objection to the cleansing sponge-bath of tepid 
water. If conjunctivitis be present the eyes should be flushed 
several times daily with a 2 per cent boric acid solution. 

In cases in which the rash is tardy in coming out, or in which 
there is a recession of the same, a warm bath or pack is of great 
service. With recession of the rash the condition often becomes 
grave. When due to cardiac failure, stimulation is indicated, 
and a warm bath is a valuable adjuvant when serious congestion 
of internal organs (bronchopneumonia, meningitis, etc.) exists 
as a complication. 

In feeding cases of measles we must bear in mind the ten- 
dency to diarrhea, just as in scarlet fever we must anticipate 
nephritis. 

During convalescence the diet should be highly nutritious, 
consisting largely of milk, eggs, fresh vegetables, lamb chops, 
etc. If a tendency to tuberculosis exists, cod liver oil may 
be added with advantage. 

Aconite corresponds to all of the early symptoms of a typical 
case of measles and it may be looked upon as a specific. As 
a rule, it is the only remedy required unless complications 
occur. 

Arsenicum is indicated in adynamic cases in which there is 
pronounced prostration; scanty rash from circulatory failure 
or hemorrhagic form of eruption; anxiety and restlessness; 
albuminuria. 

Bryonia. — Bryonia may be required for the associated 



ACUTE INFECTIOUS DISEASES 477 

bronchitis with hard, dry, painful cough. The rash is slow in 
appearing, but, when once established, it is usually abundant 
and characteristic. The accompanying symptoms are the 
cough; great lassitude and irritability; anorexia, with thirst 
for large quantities of water; constipation. Both bryonia and 
gelsemium have been credited with the power of hastening the 
appearance of a tardy rash, but there is no clinical proof that 
they can produce such a result. 

Coffea is recommended for the short, dry, teasing cough of 
measles, frequently becoming a most distressing complaint in 
nervous, delicate children. 

Euphrasia. — This remedy is useful for the eye complications 
when there is a profuse corroding discharge from the eyes, with 
profuse, bland nasal discharge (allium cepa has the opposite 
condition). 

Gelsemium. — Gelsemium may be indicated in place of aconite 
in cases of mild gradual onset where the fever is slight and 
there is slight chilliness with marked catarrhal symptoms, 
headache, drowsiness, photophobia and general aching as in 
mild influenzal attacks. 

Kali bichromicum is of value for a deep, loud cough, with 
expectoration of stringy yellowish mucus; intense conjunc- 
tivitis, sometimes going on to keratitis and ulceration ; stitches 
in the ears, extending into the head and neck ; watery diarrhea, 
with tenesmus; ulcerated sore throat. Even when the symp- 
toms are not so severe or characteristic as above stated, 
this remedy is frequently of great value, especially when 
bryonia does not control the bronchitis. It is followed by 
Pulsatilla. 

Lachesis. — Severe hemorrhagic type of the disease. 

Pulsatilla may be indicated early, although its sphere of use- 
fulness lies mostly in the clearing up of the cough and catarrhal 
symptoms lingering after measles. It is followed well by 
hepar sulph. 

Other remedies which may be called for upon special indica- 
tions are: 



478 DISEASES OE CHlLDEEH 

Belladonna in alternation with the red iodide of mercury 
may be needed when a severe angina complicates the measles. 
Belladonna is also useful for the nervous symptoms which may 
occur during the disease. 

Hepar and spongia may be required when the cough becomes 
croupy. 

Phosphorus and antimon tart, in those cases in which broncho- 
pneumonia develops. 

SCARLET FEVER. 

(SCARLATINA; French, LA SCARLATINA; German, SCHAR- 
LACH.) 

Scarlet fever is an acute eruptive fever which is highly con- 
tagious and is characterized by a sudden onset with high fever, 
sore throat and a scarlet rash, whence it derives its name. 

Scarlet fever was known to the ancients ; however to Syden- 
ham belongs the credit of first differentiating it from measles 
and of writing a clear clinical description of the disease. Since 
the eighteenth century scarlet fever has been well-known in 
Europe and the first epidemic recognized in the United States 
occurred in Massachusetts in 1795. 

Etiology. — Scarlet fever occurs in epidemics in all large 
communities usually in the fall and winter months. Sporadic 
cases may occur at any time and the disease frequently develops 
in conjunction with a severe burn when it develops outside of 
an epidemic. Scarlet fever is distinctly a disease of school age 
and is more prevalent among children at the time of year when 
they attend school than when they are living mainly out of 
doors and in less intimate contact. It is more prevalent in 
densely populated cities than in rural districts and for this 
reason more common in our latitude than in warmer countries. 
The greatest degree of susceptibility exists between the ages of 
two and six years ; infants usually escape, especially those who 
are nursing at the mother's breast. If the mother has not had 
scarlet fever the infant is perhaps as susceptible as the older 



ACUTE INFECTIOUS DISEASES 479 

child. After puberty susceptibility gradually decreases; mauy 
adults, however, contract scarlet fever, both in mild and severe 
forms. The immunity obtained from a previous attack is prac- 
tically absolute. 

While scarlet fever is not as contagious as measles, its spread 
being slower and less extensive than the latter in communities 
or non-isolated quarters harboring cases, still its causative 
agent possesses much greater tenacity to life, and is much 
more readily carried from one locality to another by means of 
a third person or by contaminated objects than measles. It re- 
tains its vitality for months, and requires active germicidal 
measures for the successful disinfection of infected places and 
articles of dress, bedding, etc. 

The period of contagiousness lasts about five weeks, begin- 
ning with the invasion of the disease, reaching its height during 
the febrile period and persisting until desquamation is com- 
plete. The source of infection lies in the catarrhal discharges 
from the nose and throat and in the pus from a suppurating ear 
or gland. It is generally held that the scales of desquamated 
epidermis cast off during convalescence from the disease harbor 
the infective agent, but this has not been proven and is now 
looked upon as an improbable cause for contagion. 

The exact nature of the causative agent of scarlet fever still 
remains obscure. Streptococci are found in the blood in a 
certain percentage of cases, but they are rather to be looked 
upon in the light of a secondary infection than as the primary 
cause of the disease. They occur with relatively greater fre- 
quency in the more severe and protracted cases, but they may 
be absent in some of the fatal cases. Mallory has demonstrated 
certain bodies in the skin of four cases of scarlet fever, which 
he considers one of the stages in the development of a protozoon. 
Inclusion bodies have been found in the polynuclear leucocytes 
by Dohle and others but they have also been found in other con- 
ditions where there was a streptococcus infection and cannot, 
therefore, be considered specific. The period of incubation is 



480 DISEASES OF CHILDREN 

short, usually less than a week, and in many cases only two to 
three days. 

Symptoms. — The course of a typical case of scarlet fever 
may be divided into the stage of invasion, stage of eruption and 
stage of desquamation. Prodromata are rare, the invasion 
being abrupt, with fever, headache, vomiting and sore throat. 
Such a combination of symptoms occurring in a child should 
always lead one to suspect scarlet fever. The temperature may 
rise very rapidly to a high point, reaching 104° F. and over; 
in mild cases, however, it may rise but inconsiderably. The 
pulse likewise is affected in a characteristic manner, attaining 
a rapidity of one hundred and twenty to one hundred and thirty 
beats per minute quite early in the attack. The throat is 
highly inflamed, a diffuse erythematous blush covering the 
tonsils, pharynx and soft palate. Later in the disease diph- 
theritic patches may appear (pseudo-diphtheria). 

The rash. — Within from twelve to thirty-six hours from the 
beginning of the fever the eruption makes its appearance, first 
showing itself about the neck and chest, whence it rapidly 
spreads over the entire body, this being accomplished within 
twenty-four to thirty-six hours, or in even a shorter period of 
time. It develops most intensely on the neck, over the 
extensor surface of the extremities, about the joints, and on the 
dorsum of the hands and feet. A peculiar pallor about the 
mouth is frequently seen, producing a striking contrast with 
the flushed cheeks, and giving rise to the characteristic "white 
line" of the disease. The eruption is due to intense hyperemia 
of the skin, accompanied by exudation of serum and round cells 
into the rete Malpighii, the process ending in death of the 
epidermis, with desquamation of variously-sized scales and 
flakes. The predominating feature in the pathology of the 
cutaneous manifestations is vascular paralysis. When typical, 
the rash consists of numerous, closely-aggregated red points, the 
size of a pin-head, evenly distributed over the entire body, 
giving it a bright, scarlet color. The eruptive points may be 



ACUTE INFECTIOUS DISEASES 481 

but slightly red in the beginning, later assuming the bright, 
scarlet hue. The rash is more frequently a dull red than scarlet, 
and the general effect is produced by the erythema associated 
with puncta, fine vesicles and more or less goose flesh. The 
punctate spots are the result of inflammation around the hair 
follicles, and they may become large enough to impart to the 
skin a distinctly rough feel. The points may be flat or elevated, 
round or lentil-shaped, and with increasing hyperemia they 
become confluent, the skin becoming turgescent and tense. The 
swelling is most marked about the face and eyes. Another de- 
viation from the usual eruption is the appearance of roseola- 
spots of various sizes and shapes, separated by pale areas of 
skin (scarlatina variegata). In some cases the rash does not 
become general, often being absent from the face. It may be 
extremely faint in color, or assume a deep purplish hue, or be- 
come hemorrhagic. 

At the height of the eruption the skin is burning hot to the 
touch, and the patient complains of burning, stinging and 
itching; at this time also, all other symptoms are most intense. 

Pressure with the finger causes momentary disappearance of 
the rash, which re-appears from the periphery toward the 
center, differing in this respect from the rash of measles. If 
the finger be drawn across the skin a pale line is temporarily 
caused by the pressure of the finger which soon disappears but 
after a few seconds it re-appears and may persist for several 
minutes. 

Fever. — The temperature curve of scarlet fever is one of 
abrupt onset, the fever running high with slight remissions 
during the first three or four days and then gradually subsid- 
ing by lysis. The average duration is one week. 

The tongue is heavily coated; the edges, however, remaining 
red. In the course of a few days the coating is shed, leaving the 
red and swollen papillae exposed, with the resulting character- 
istic appearance described as "strawberry tongue." Enlarge- 
ment of the papillae of the tongue is such a constant symptom 
32 



482 DISEASES OF CHILDREN 

of scarlet fever that it becomes a most valuable diagnostic 
sign. Indeed, McC'ollom, of Boston, looks upon this symptom, 
when occurring in association with fever and sore throat, as 
pathognomonic of scarlet fever, irrespective of the presence of 
a rash. In mild cases, however, the enlargement of the papilla? 
may fail to develop. 

The throat presents a characteristic intense general redness 
with fine red points on the hard palate. In some cases the 
throat manifestations are intensified and patches of membrane 
will be seen upon the tonsils which may spread to the soft palate 
and adjacent parts. This complication is usually due to strep- 
tococci and clinically is a pseudo-diphtheria. True diphtheria 
is rare during the course of scarlet fever, and, when associated 
with the same, it occurrs as a sequel rather than as a 
complication. 

Otitis is a frequent complication occurring at the height of 
the disease, the result of an extension of infection from the 
post-nasal space. It usually terminates in suppuration, and is a 
prolific cause of the serious types of deafness occurring in 
childhood. When occurring during convalescence its advent 
is more readily anticipated, as there is recurrence of fever, with 
distinct earache and impairment of hearing. 

Parotitis and cellulitis of the neck sometimes accompany the 
septic process in the throat. The termination of such a process 
is usually in suppuration. Likewise the tonsils and lymphatic 
glands of the neck may be involved in suppurative inflam- 
mation rendering the prognosis most unfavorable. 

Synovitis of the larger joints is prevalent during some 
epidemics. It develops between the first and second weeks. 
The duration is short, never ending in suppuration. Endo- 
carditis may complicate such an arthritis. 

The blood shows a well-marked leucocytosis, the polynuclears 
predominating. During the second week a marked eosinophilia 
may develop. The more intense the infection the higher the 
leucocytosis. In asthenic cases, however, there may be a 






ACUTE INFECTIOUS DISEASES 483 

failure on the part of the organism to react and in such cases 
a low leucocyte count offers a grave prognosis. 

The lymphatic glands, both the subcutaneous as well as the 
lymphatic structures of the viscera, are involved. There is 
more or less general adenopathy, the cervical inguinal and 
axillary glands being especially affected. A post-scarlatinal 
adenitis may develop during convalescence, involving the cer- 
vical glands. There is usually a return of fever with this 
complication. 

Post-scarlatinal nephritis is one of the most constant and 
most important complications of scarlet fever, occurring typic- 
ally during the third week. Pathologically, it is an acute, 
diffuse, productive nephritis. It is a more serious condition 
than the simple acute degeneration or acute exudative nephritis 
which may occur early in the course of the fever, just as in 
any other acute infectious disease. There is scanty urine and 
general dropsy, and suppression of urine and uremia may 
supervene. Although the kidney is much damaged at the time, 
still many cases clear up completely and show no evidence of 
a former nephritis in later life. 

Desquamation begins shortly after the rash has faded — 
about the end of the first week. It begins in the localities in 
which the rash first appeared, as scales of varying size about 
the neck and chest. Gradually the entire trunk is involved in 
the process, desquamation being completed here long before the 
fingers and toes have shed their epidermis. On the latter, 
especially where the skin is thick, the peeling process is slow, 
and large pieces of skin, sometimes complete casts of the 
fingers, are detached in the "moulting" process. In cases where 
desquamation is slight, it may be found characteristically by 
about the tenth day at the tips of the fingers. A separation of 
the epidermis at the edge of the nail-bed, producing the line 
of "subungual cleavage," is a characteristic phenomenon. 

Prognosis. — The prognosis depends to a great extent upon 
the character of the epidemic; the general health of the child 



484 DISEASES OF CHILDREN 

before the attack; the height of the fever, and the severity of 
the attending complications. As a rule, the disease is more 
likely to prove fatal if the child is very young, especially when 
serious throat involvement, adenitis or otitis are associated. 
The degree of toxemia and the state of the peripheral circula- 
tion are important prognostic indications. A livid rash or 
recession of the rash, indicating failing circulation, are unfavor- 
able signs. Cases marked by sudden onset with high fever 
and delirium offer a grave prognosis on account of the high 
degree of toxemia they present. Some cases prove fatal within 
the first twenty-four hours before the rash appears — "malignant 
scarlet fever." 

Nephritis is the chief danger to be feared after convalescence 
has been established. The scarlatinal toxin possesses a specific 
affinity for the parenchyma of the kidney, and no matter how 
mild the attack may have been, one can never feel certain that 
nephritis will not develop. 

Convalescence is usually protracted owing to an anemia, 
otorrhea and nasal catarrh, adenitis, post-scarlatinal nephritis. 
Diagnosis. — Scarlet fever differs from measles in the abrupt- 
ness of its onset, the presence of sore throat and the absence 
of Koplik's spots and catarrhal symptoms. The desquamation 
in scarlet fever is also different from that observed in measles. 
From rubella it is distinguished by the sudden onset and high 
fever with pronounced sore throat, by the characteristic appear- 
ance of the tongue, and by the occurrence of desquamation. 
Symptomatic rashes can usually be traced to the partaking 
of certain articles of food or the administration of certain 
medicines, or to the sepsis or auto-intoxication. The rash is 
of short duration, sore throat is absent, and in the absence of 
gastric derangement the temperature is normal. Many of the 
infectious fevers are at times accompanied by an erythematous 
rash, causing considerable confusion as to the true nature of 
the case. All doubtful cases, however, followed by the typical 
desquamation and associated with albuminuria, are to be looked 






ACUTE INFECTIOUS DISEASES 485 

upon as scarlatina. The serum-rash sometimes observed after 
the administration of antitoxin is urticarial in character, lacks 
the puncta and diffuse distribution of scarlet fever and the 
blood shows a leucopenia. 

The history of the exposure to infection is an important 
point in atypical and incomplete cases, as is also the appearance 
of the tongue and the presence of general adenopathy. The 
presence alone of scaling is not a proof that the case is one of 
scarlet fever, and scaling may be more pronounced in certain 
cases of desquamative scarlatiniform erythema than in ordinary 
scarlet fever. The time of onset, mode of progress and its 
persistence are of more importance than the mere presence of 
scaling (Schamberg). On the other hand, in a case of scarlet 
fever with well-developed rash and subsequent marked des- 
quamation, the associated conditions, namely, fever, prostration, 
sore throat and adenopathy, are more pronounced than in the 
scarlatiniform erythemata. 

Treatment. — With the occurrence of suspicious symptoms 
the patient should be immediately isolated. From this time 
on until desquamation is completed, and, if practicable, until 
all discharges have been controlled, the child should be kept 
away from others to whom or through whom it may convey the 
contagion. Five weeks from the beginning of the attack is 
usually a sufficient period of quarantine, excepting in cases 
with an otorrhea or any other complication in which there is 
a purulent discharge. 

The bedroom should be freely ventilated, and all unnecessary 
articles of furniture and hangings should be removed, but not 
after they have been exposed to the contagion, unless they 
can be immediately disinfected. A sheet wrung out of a 2 
per cent solution of carbolic acid and hung in front of the 
door adds to the completeness of the isolation. All kitchen 
utensils, etc., used by the patient should be immersed in a 
4 per cent solution of carbolic acid or formaldehyde for an 
hour before being removed from the room. They should then 



486 DISEASES OF CHILDREN 

be scalded, or, better still, boiled for a quarter of an hour. 
The nurse and the attending physician should protect their 
outer clothing by wearing a long, linen coat on entering the 
sick room, and disinfect their hands before leaving the room. 
All sheets, rags, articles of clothing and furniture that can be 
dispensed with are best burned. The room must be thoroughly 
fumigated after the patient has recovered, and the bed clothes 
and mattress sterilized. 

The itching of the skin may be relieved by rubbing the body 
daily with cocoa butter or cocoanut oil. The inunction of fats 
not only relieves the itching and burning of the skin, but it 
also acts as a sedative and at times reduces the fever. 

In case of high fever a sponge-bath of tepid water and 
alcohol (one part of alcohol to three of water) is of great service. 
In the advent of anasarca or suppression of the urine a warm 
pack should be used. For the angina, a spray of alcohol one 
part, glycerin one part and water three parts, may be used 
several times daily. Likewise, the nose should be kept scrupu- 
lously clean by means of douches of a normal saline solution 
or Dobell's solution. 

The diet should be restricted to non-nitrogenous foods. 
Solid food, especially meat, should be prohibited until after the 
third week, and in case of nephritis, a milk diet must be 
adhered to for a still longer period. 

The remedies of first importance in scarlet fever are the 
following : 

Belladonna is as nearly specific to scarlet fever in its symp- 
tomatology as any remedy can possibly be. The fever, head- 
ache, sore throat and rash are all covered homeopathically by 
belladonna. It is to be questioned, however, whether bella- 
donna can prevent the disease as some have claimed, but given 
early it can certainly modify the severity of the symptoms. 
When the throat symptoms become unusually severe, develop- 
ing into an actual pseudo-diphtheria, mere. iod. rubr. should be 
alternated with belladonna. 






ACUTE INFECTIOUS DISEASES 487 

Rhus tox is indicated in the more toxic types of scarlet fever 
when there is great prostration and restlessness. Also in the 
advent of albuminuria early and when rheumatic symptoms 
develop. 

Arsenicum is useful when there is profound prostration, 
nephritis and anasarca. Petechial eruption. 

Cuprum. — Sudden recession of the eruption, with occurrence 
of cerebral symptoms. The acetate of copper is generally pre- 
ferred. The arsenate of copper should be thought of when the 
condition is one of uremia. 

Gelsemium. — In the early stages, when there is the character- 
istic dulness and drowsiness; aching and prostration; soft, 
compressible pulse ; aching in the eyes and back of head. The 
throat is red and feels swollen; the eyes are suffused, and the 
patient feels chilly, especially along the spine. 

Lachesis. — Scarlatina miliaris. Eruption becoming purple 
and livid; desquamation delayed; hematuria (terebinthina) ; 
oppression when lying down ; diphtheric complication ; diarrhea 
with foul smelling stools. 

Ailanthus. — Miliary rash ; small, rapid pulse ; the eruption 
becomes dark and livid; intense angina, with acrid discharge; 
muttering delirium followed by stupor. 

Complications and Sequelae. — Throat complications call 
for pliytolacca, the various salts of mercury, hali bichrom., per- 
manganate of potash. (See diphtheria.) 

Cellulitis and Parotitis. — The most important remedy for 
this complication is rhus tox. Suppuration calls for hepar, 
mercurius, silica. 

Otitis. — Bell., puis., rhus tox., capsicum (mastoid in- 
volvement). 

Cerebral complications. — Apis, bell., helleb., hyos., stram., 
sulph., and zinc. 

Nephritis. — Cantharis is a most valuable remedy in post- 
scarlatinal nephritis when there is not much blood in the urine 
and only moderate dropsy. When the latter is pronounced 



488 DISEASES OF CHILDREN 

apis and arsenicum are of greater service. The characteristic 
"smoky" appearance of the urine frequently seen after scarlet 
fever, from the free admixture of the blood, is a strong indica- 
tion for terebinthina. Persistent albuminuria after scarlet 
fever calls for mercurius corr. 

RUBELLA. 

Rubella, Rothelm, or German Measles, is a mild exanthema- 
tous disease characterized by slight fever and a macular rash, 
usually occurring first on the face and involving the entire 
body. It presents a superficial resemblance to measles in most 
instances. Sometimes it is confused with the milder types of 
scarlet fever. Complications or sequelse are absent. It usually 
occurs epidemically, and one attack confers immunity but in 
no wise protects against measles or scarlet fever. 

Nothing definite is known of its etiology. It is contagious, 
but less so than measles or scarlet fever; nevertheless, it may 
be spread by articles of clothing, etc. Infants under six months 
are immune. The incubation period is from two to three weeks, 
but it may show considerable variation in this respect. 

Symptoms. — The period of invasion is short, prodromata 
usually being absent. Drowsiness and fever may precede the 
eruption for a day or more in some cases; as a rule, the rash 
is the first evidence of the disease. The characteristic enlarge- 
ment of the posterior cervical glands which is present from the 
beginning is of the greatest help in the early diagnosis of 
rubella. The rash is first seen upon the face, from which it 
spreads over the entire body in the course of twenty-four 
hours. Although the face is the most constant site of the 
eruption, even when the rash is developed but partially, still 
the chest and back may show the first signs of eruption in 
exceptional cases. The duration is about three days. Often it 
has completely faded from the face by the time the lower ex- 
tremities are involved. There is no characteristic desquamation. 

In rubella morbilliforme there is seen a discrete, maculo- 



ACUTE INFECTIOUS DISEASES 489 

papular rash of pale red color, the eruptive points being slightly 
elevated and about the size of a pin's head or larger. These 
lesions have a tendency to become confluent upon the face, 
particularly so when they are numerous. 

In rubella scarlatiniforme the rash is of a diffuse, uniform, 
scarlet color, never as intense, however, as in scarlet fever, 
and with unmistakable evidence of the maculopapular eruptive 
points in various localities (on the forehead, fingers and toes, 
and about the wrists). 

In some instances the diagnosis can only be made after 
the mild course of the disease has been noted, in conjunction 
with the absence of complications and sequelae. When, how- 
ever, there is an epidemic, and especially if the child has 
previously had one of the other exanthemata, the diagnosis 
presents little difficulty. The enlargement of the posterior 
cervical glands is the most characteristic symptom of rubella. 
From measles it is differentiated chiefly by the absence of 
catarrhal symptoms, absence of Koplik's spots and the slight 
fever. From scarlatina the absence of sore throat and straw- 
berry-tongue, the rash first appearing upon the exposed portions 
of the body, the low temperature and absence of desquamation 
and nephritis readily differentiate it. 

The treatment is symptomatic. (See treatment of Measles.) 



DIPHTHERIA. 

Diphtheria is a highly contagious disease characterized by 
the presence of an infection of the throat which is accompanied 
by the formation of a false membrane upon the tonsils. The 
membrane may spread to the adjacent structures and invade 
the nose, larynx and bronchi. Death may result from suffoca- 
tion through the spread of the membrane into the larynx. 
In the majority of cases, however, constitutional symptoms, 
resulting from the absorption of the toxin generated by the 
germ which causes the disease, are of greater importance than 



490 DISEASES OF CHILDREN 

the mechanical effects of the membrane and most fatalities are 
due to toxemia. 

The disease was apparently known to the ancients. In the 
American colonies it was noted in Boston in 1735 and in New 
York it was described by Dr. Samuel Bard in 1771 as "suffoca- 
tive angina. " The first scientific article upon diphtheria was 
written by Bretonneau in 1812 and the term diphtheria was 
coined by this author. 

Membranous croup was recognized by the older clinicians 
and was correctly differentiated from spasmodic croup and 
properly treated by them with tracheotomy. This operation was 
first conceived by Bretonneau but its technique was finally 
perfected by Trousseau. In the days of Trousseau, however, 
the identity of diphtheria and membranous croup was not recog- 
nized and even in recent years the diphtheritic nature of 
membranous laryngitis was questioned by some clinicians 
owing to the absence of membrane in the throat and the com- 
paratively slight constitutional symptoms which accompany it. 

Etiology. — Diphtheria is distinctly a disease of childhood. 
Thousands of cases occur annually among children in all large 
cities. In order to contract the disease an individual must show 
susceptibility as well as come in contact with a case of diph- 
theria. An apparently healthy person with a natural resistance 
to diphtheria may, however, harbor the germs of diphtheria 
in his throat and so become a "carrier" and infect others who 
do not possess sufficient natural resistance. Individual resist- 
ance or susceptibility can be accurately demonstrated by 
means of the Schick test and from the results of the examina- 
tion of large numbers of persons it has been learned that in 
childhood susceptibility to diphtheria is very much higher 
than in adults. Schick and Park have found that about 80 
per cent of the newborn are immune; Park believes that this 
immunity is due to the infant receiving a certain amount of 
antitoxin in the colostrum. From the end of the first year 
to the end of the fifth year the percentage of positive Schick 



ACUTE INFECTIOUS DISEASES 491 

reactions is from 50 to 65 per cent, the highest figures occur- 
ring from two to four years. In adults there is a susceptibility 
of only about 25 per cent. Age and exposure, therefore, are 
the chief etiological factors in diphtheria. A child in the early 
stage of diphtheria may spread the disease to others by droplet 
infection during coughing and sneezing or he may transmit it 
indirectly by means of toys, pencils, eating utensils, handker- 
chiefs, etc. This mode of infection is more likely to take place 
during convalescence especially from mild cases which are 
not recognized as diphtheria and properly isolated. Like many 
other infectious diseases it may also be spread by means of a 
contaminated milk supply. Cats have been blamed as carriers 
but this has not been proven. 

Diphtheria is endemic in all large cities but there are always 
periods of outbreaks affecting many children at a time. While 
in the rural districts and in communities without strict health 
supervision epidemics still attain considerable magnitude, this 
seldom occurs in large cities. Schools are closed temporarily 
if necessary and immunizing doses of antitoxin are administered 
gratis by Boards of Health when the expense for such a pro- 
cedure cannot be borne by the parents and in this manner 
outbreaks of the disease are soon controlled. The medical 
inspection of school children has been a strong factor in the 
control of diphtheria. Unfortunately, however, many mild 
cases still go unrecognized and untreated and make the complete 
control of the disease a difficult problem. 

The Klebs-Loeffler bacillus, is the etiological factor in diph- 
theria. This is a bacillus varying in size, being broad, straight 
or slightly curved and presenting a club-like extremity. It 
contains highly refractile, oval bodies which take the stain 
more deeply than the bacillus itself. The best stain for bring- 
ing out these bodies is an acidulated solution of methylene blue ; 
a counter-stain of aqueous Bismark brown is used to stain the 
body of the bacillus. This is known as Neisser's stain and the 
most characteristic results are obtained in young cultures grown 



492 DISEASES OP CHILDREN 

from six to twelve hours. The bacillus grows readily upon 
Loeffler's blood-serum at a temperature of from 80° to 100° F., 
and it is therefore a simple matter to make a culture from a 
suspected case of diphtheria. The examination of smears from 
the throat is not accurate; Vincent's angina, however, may be 
differentiated from diphtheria by this procedure. 

Pathology. — Diphtheritic membrane is most frequently 
found on the tonsils, soft palate, pharynx and larynx in fatal 
cases. It may extend into the nose or down into the trachea. 
The membrane which forms on mucous membrane covered with 
squamous epithelium such as the nose and throat is more firmly 
attached than that formed in the trachea which is lined with 
columnar epithelium. The color and consistency depend upon 
the amount of fibrin present, the admixture of blood and the 
presence of a mixed infection. 

The membrane consists of a dense network of fibrin in the 
meshes of which pus cells, epithelial cells and bacteria are 
seen. The K\lebs-Loeffler bacillus can be demonstrated on 
the surface and at the periphery of the membrane. The 
mucous membrane underlying and adjacent to the pseudo- 
membrane is found in inflammatory reaction with a distinct 
zone of hyperemia at the periphery of the false membrane. 
When the latter is roughly detached a bleeding surface will be 
left. 

The lymphatic glands of the neck are markedly swollen, but 
do not break down. The surrounding structure may present 
a puffy appearance. The glandular enlargement is most marked 
in cases complicated by an invasion of the posterior nares. 
When the process is confined to the larynx there is but slight 
glandular involvement. 

The toxemia which is associated with diphtheria produces 
pathological changes widely distributed throughout the body. 
Parenchymatous degeneration of the heart, kidneys and liver 
are the changes observed in the internal organs. A secondary 
bronchopneumonia is rarely absent in severe and fatal cases. 



ACUTE INFECTIOUS DISEASES 493 

In such cases the Klebs-Loeffler bacillus is usually found in the 
lungs. In sixty-two cases of bronchopneumonia, associated 
with diphtheria, reported by Pearce, (Jour. Bost. Soc. Med. 
Sciences, June, 1897) the bacillus was present in fifty-two in- 
stances, being the only organism present in seventeen cases. 
The changes occurring in the nervous system are parenchyma- 
tous degeneration of the myelin sheath of the nerves (multiple 
neuritis) and at times degenerative changes in the ganglion 
cells of the cord. 

Symptoms. — The onset is not characteristic as in most other 
acute infectious diseases. The chief complaint is sore throat 
and malaise and although the child is feverish it may not feel 
sick enough to go to bed. If the throat is examined at this time 
it will be noted that the color is of a deep red and a small 
grayish patch will be found on one of the tonsils. The breath 
is offensive and the sub-tonsillar lymph node is enlarged. If 
prompt treatment is instituted at this stage of the disease the 
temperature soon falls to normal and the spread of the mem- 
brane is arrested. It is loosened from its attachment to the 
mucous membrane and promptly disintegrates. If, however, the 
disease is not recognized and treatment is delayed there is a 
rapid spread of the membrane to the pillars of the pharynx 
and soft palate and the opposite side becomes infected. The 
adenopathy increases and fever and toxemia become more 
pronounced. 

The membrane is of a grayish or yellowish color, and is 
firmly adherent to the subjacent mucous membrane. It has a 
sharply defined border and is surrounded by a red zone of 
hyperemia. The membrane cannot be detached without injury 
to the underlying structure. When antitoxin is promptly ad- 
ministered it frequently curls up at the edge and spontaneously 
separates from the mucosa. More or less edema of the soft 
palate is usually present. Instead of beginning as a single 
patch, there may be seen isolated dead-white spots of varying 
size upon one of the tonsils. Usually they unite into one large, 



494 DISEASES OF CHILDREN 

irregular patch, and the opposite tonsil soon develops a similar 
membrane. 

In a steadily progressive (untreated) case the above dis- 
tribution of the membrane will have been completed in about 
three to four days from the time of onset. At this time the 
membrane can be studied in various stages of development. At 
the site of origin it will be found to have attained considerable 
thickness, being of a brownish or dirty grayish color, with a 
well-defined outline and areola, and a thick, partly detached 
border, while in another direction it fades out into a thin, 
grayish film, which is invading new territory. This film like- 
wise thickens and assumes the same color as the other portion 
of the membraue. 

By the fifth or sixth day, in such cases, the process has 
reached its acme, and in a few days the membrane separates 
spontaneously. A red areola of reactionary inflammation is 
seen about its border, and it gradually loosens and comes away 
in pieces, leaving behind a reddened, slightly swollen and read- 
ily bleeding mucous membrane. The patient has recovered 
from his throat infection but there has been so great an absorp- 
tion of toxin that diphtheritic paralysis with probably heart 
failure or respiratory paralysis are to be anticipated. 

The general symptoms which are observed in conjunction with 
the severe throat manifestations just described are gradually 
increasing prostration ; a rising temperature and pulse rate ; 
offensive breath; difficulty in swallowing; nasal voice and 
pronounced cervical adenopathy. 

The heart is affected by the toxin of diphtheria from the in- 
ception of the disease. The pulse is rapid from the time of 
onset and its rate is disproportionate to the temperature. An 
actual tachycardia with a pulse rate of 150 to 160 per minute 
may be encountered in the more severe types of diphtheria. 
When antitoxin is given early and in sufficient dosage a prompt 
improvement in the pulse rate is noted. The heart, however, 
must be watched for several weeks after every case of diph- 



ACUTE INFECTIOUS DISEASES 495 

theria and the child kept at absolute rest so long as there is any 
abnormality in the pulse. A systolic murmur, indicating a 
relative insufficiency of the mitral valve from dilatation is often 
observed after diphtheria and may persist for weeks. (Irreg- 
ularity of the pulse is also common during convalescence.) 
The chief danger, however, lies in the development of heart 
block. This usually occurs at the beginning of the second week 
in cases which did not receive antitoxin early. There is a 
sudden drop in the pulse-rate which may fall as low as 30 to 40 
per minute; there is pallor, apathy and prostration and the 
child often vomits and complains of epigastric pains. These 
symptoms are the most serious ones that can be encountered in 
diphtheria, aside from paralysis of the muscles of respiration 
which is a later development. The majority of cases of com- 
plete heart block terminate fatally within a few days. 

Diphtheritic paralysis occurs more frequently in adults and 
older children than in young children; it is seldom seen in 
infants. Cases which have received a sufficient dosage of anti- 
toxin during the first twenty-four hours of the disease rarely, 
if ever, develop paralysis. 

The symptoms are those of a multiple neuritis. In the 
majority of cases symptoms do not occur until the second or 
third week. Paralysis of the soft palate is the first symptom 
noticed, manifesting itself by nasal voice, regurgitation of 
food through the nares, and difficulty in swallowing. 

The eye-muscles are frequently affected early, and loss of 
accomodation, strabismus and ptosis are the disturbances en- 
countered here. When the extremities take part in the paraly- 
sis the patient complains of muscular weakness, with tingling 
and numbness, gradually increasing in severity until he is 
perhaps unable to walk or use his arms, although complete 
paralysis is rare. The distribution of the paralysis is symmet- 
rical. Sensation is markedly impaired and the knee-jerk lost, 
even, at times, without the existence of paralysis. The prog- 
nosis as to ultimate recovery is good, although the course is 



496 DISEASES OE CHILDREN 

variable, some cases continuing for several months before im- 
provement sets in. Death may result from paralysis of the 
respiratory muscles or from involvement of the vagus. This 
is characterized by vomiting, epigastric pains and weak, irreg- 
ular pulse. 

Extension of the membrane to the nose is indicated by nasal 
obstruction with an acrid, offensive, muco-purulent discharge 
and increased swelling of the lymphatic glands at the angle of 
the jaw, together with involvement of the submaxillary glands. 
Epistaxis occurring during diphtheria is always a suspicious 
symptom. Owing to the large absorbing surface brought in 
contact with the toxin, constitutional symptoms are markedly 
aggravated, and prostration becomes extreme. Primary nasal 
diphtheria is, as a rule, not nearly as grave a condition as the 
secondary form, although such a case may infect another child 
with a f aucial diphtheria of the usual severity. 

Extension into the larynx is indicated by progressively 
increasing dyspnea, cyanosis, and a croupy cough. The process 
may result in complete stenosis of the larynx, with death 
from suffocation. 

Septic diphtheria is a term applied to a severe type of the 
disease with pronounced throat symptoms, foul breath, marked 
adenopathy and high fever. 

Primary Laryngeal Diphtheria. — Laryngeal diphtheria 
or membranous croup is a primary infection of the larynx 
characterized by the formation of a false membrane (croupous 
exudate) upon the laryngeal mucous membrane. The false 
membrane may remain confined to the larynx, or extend down 
into the trachea, Often it is accompanied by a scanty tonsillar 
exudation. Laryngeal diphtheria differs clinically from faucial 
diphtheria in the absence of the marked constitutional symp- 
toms and adenopathy observed in the former. This may be due 
in part to a difference in the type of organism showing a 
predilection for the larynx rather than for the throat. A better 
explanation, perhaps, is the fact that the mucous membrane 



ACUTE INFECTIOUS DISEASES 497 

of the larynx does not absorb toxin as readily as that of 
the fauces. 

The onset is insidious, with moderate fever, croupy cough, 
and hoarseness. During the first twenty-four hours the symp- 
toms are laryngeal ; the child is hoarse and has a hard, croupy, 
non-productive cough. This may at first be mistaken for 
catarrhal croup but the cough and difficulty in breathing 
persist throughout the day and progressively increase. Com- 
plete aphonia soon develops. Recession of the epigastric region 
during inspiration indicates an on-coming stenosis of the larynx 
and with the increasing stenosis breathing becomes a purely 
voluntary effort. The child now sits erect, and with every 
effort at inspiration the accessory respiratory muscles are 
thrown into action. The body surface is cold and cyanotic, 
and the child becomes drowsy and later comatose, dying from 
asphyxia. Death may result in a few days from the time of 
onset, unless antitoxin has been used early. As soon as labored 
breathing develops intubation should be performed. 

Pseudo-Diphtheria differs from true bacillary diphtheria 
both etiologically and symptomatically, being caused by a strep- 
tococcic infection of the throat. It may develop independently 
or complicate scarlatina, measles, etc. As a complication of 
scarlatina it appears, however, more frequently and more viru- 
lently than in any other form. 

The clinical course of pseudo-diphtheria differs distinctly 
from that of bacillary diphtheria. In pseudo-diphtheria there 
is pronounced inflammation of the pharynx and tonsils with 
redness, swelling and pain. It begins abruptly, with high fever, 
lassitude and headache. Small, white or yellowish patches 
develop upon the tonsils, they become darker in color and may 
coalesce, but seldom spread beyond the tonsils, in this respect 
differing distinctly from the membrane of true diphtheria. The 
membrane is more friable than that of diphtheria, and can 
usually be detached without difficulty and without injury to 
the under-lying mucous membrane. 
33 



498 DISEASES OF CHILDREN 

Marked swelling of the lymphatics seldom takes place. . It 
may occur in epidemic form as the so-called "septic sore throat." 
The duration is from four to five days and although constitu- 
tional symptoms are severe during the height of the disease, the 
throat symptoms being particularly distressing, still they are 
never of a dangerous character and sequelae are rare. Paralysis 
never follows pseudo-diphtheria, nor is extension to the larynx 
to be feared. 

Prognosis. — The prognosis of diphtheria depends so defin- 
itely upon the question of early treatment with antitoxin that 
other factors are only of secondary importance. Unfortunately 
many cases are not recognized in time to receive prompt treat- 
ment or the administration of antitoxin is delayed. Aside from 
the question of treatment the following points should also 
be considered: 

The age is of importance, as diphtheria is uniformly more 
fatal in infants than in older children. Adults present the best 
chances, but they are more subject to paralytic sequelae. 

The character of the epidemic is of some importance, as there 
is a difference in the virulence of cases from time to time. A 
most virulent diphtheria, however, may originate from an appar- 
ently mild diphtheritic sore throat, and vice versa. 

The appearance and distribution of the membrane offer 
suggestions for a prognosis, but here again errors are liable 
to occur. Cases with extensive membranous deposit may 
make a good recovery without any sequelae while one with a 
scanty membrane may be accompanied by grave toxemia. 

The time at which treatment was begun and the patient's 
general condition, therefore, offer the safest guides in deter- 
mining his chances for recovery. So long as the pulse remains 
good and the child can take nourishment satisfactorily the case 
should not be despaired of. 

In membranous croup the prognosis is more favorable than 
in secondary laryngeal diphtheria. 

During convalescence there is danger of cardiac failure from 



ACUTE INFECTIOUS DISEASES 499 

neuro-muscular deficiency. This may appear as progres- 
sively increasing heart weakness with irregular pulse or occur 
suddenly or after some physical exertion. The child is seized 
with epigastric pain and vomiting; there is dyspnea; cyanosis; 
small, irregular pulse and collapse. Heart block often develops 
in these cases. If the first attack does not prove fatal there is 
usually a recurrence with a fatal issue. 

Bronchopneumonia occurring with diphtheria is very un- 
favorable; it is especially serious when complicating croup. 

Diagnosis. — The throat of every child that is acutely ill 
should be routinely examined no matter whether it complains 
of sore throat or not. In the event of an exudate or mem- 
branous deposit being discovered on the tonsils a culture should 
be made for determining the presence of the Klebs-Loeffler 
bacillus. "When the clinical indications are strongly in favor 
of the diagnosis of diphtheria, antitoxin should be administered 
without waiting for the results of the culture. 

The differential diagnosis rests mainly between pseudo- 
diphtheria and follicular tonsillitis. Pseudo-diphtheria is 
abrupt in onset ; lymphatic swelling is absent in primary cases, 
fever is high, and the throat is markedly reddened and swollen, 
and there is considerable pain on swallowing; the exudate is 
purely fibrinous, and it does not tend to spread beyond the 
tonsils. Secondary cases occur during the febrile period of 
scarlet fever. Paralysis never follows, and although septic 
symptoms may be present the specific toxic symptoms of diph- 
theria are absent. The membrane is thinner, can be removed 
without bleeding, and is usually of a yellowish color, later be- 
coming dirty. 

In follicular tonsillitis both tonsils are uniformly swollen 
and covered with small, round, white spots, which are not ad- 
herent to the mucous membrane, but consist of plugs of exuda- 
tion filling the crypts of the tonsils, from which they can be 
readily wiped off. 

Treatment. — A child with a sore throat should be isolated 



500 DISEASES OF CHILDREN 

and if the case proves to be one of diphtheria this isolation 
must be continued until recovery is complete and two successive 
negative cultures from the throat have been obtained. Isola- 
tion and sick-room hygiene are carried out as in the case of 
other contagious diseases, like scarlet fever, for example. The 
dishes used by the patient should not leave the sick-room while 
all articles of clothing and laundry should be disinfected before 
they are taken out of quarantine. The child should use rags 
or paper handkerchiefs and these should be burned. 

Other members of the family who have been exposed to the 
patient should receive an immunizing dose of antitoxin unless 
they present a natural immunity to the disease. 

The Schick Test. Schick (Muenchner Med. Wochenschrift, 
1913) devised a practical means of determining individual 
susceptibility to diphtheria which has been used for the purpose 
of determining whether or not children exposed to diphtheria 
should receive an immunizing dose of antitoxin. The reaction 
depends upon the observation that certain individuals possess 
natural antitoxin in their blood while others do not, and that 
when a small dose of diphtheria toxin is injected intradermally 
into an individual not possessing a natural immunity a marked 
local reaction results. In the case of individuals who are im- 
mune there is no reaction. A positive reaction therefore in- 
dicates that the person is susceptible to diphtheria and is in 
danger of becoming infected. 

The test is performed by injecting 1 / 50 of the minimum 
lethal dose of diphtheria toxin for a guinea pig, diluted with 
0.1 c.c. salt solution, intradermally into the skin of the fore- 
arm. A similar injection of plain salt solution is used as a 
control. A positive reaction is indicated by the appearance, 
within 24 or 48 hours, of an area of redness which is at its 
height on the third day and then gradually fades, leaving a 
brownish discoloration and slight itching and desquamation. 

The diet should be concentrated and highly nutritious, and 
stimulation is of the greatest importance as soon as the toxic 



ACUTE INFECTIOUS DISEASES 501 

influence of the diphtheria virus upon the heart and nervous 
system becomes apparent. A teaspoonful of whisky well 
diluted with water or milk, and administered every three hours, 
suffices for the average case ; but where there is prostration and 
failing heart the quantity must be increased accordingly. Ab- 
solute rest is to be enjoined during convalescence as well as 
during the disease in all cases showing cardiac weakness, in 
order to avert a possible sudden death from acute dilatation of 
the heart. 

In regard to local treatment, it can be stated that all measures 
which in any way give the patient pain or discomfort and re- 
quire physical restraint, will do more harm than good. A gar- 
gle of permanganate of potash (1 to 1,000) is useful. Alcohol 
diluted with four or five parts of water is also a good gargle 
and is more agreeable to the patient than the permanganate. 

In nasal diphtheria the nasal chambers should be kept as 
free from secretion as possible. A douche of warm normal 
saline solution should be used about three times daily, great 
care, however, being exercised to avoid getting the fluid into 
the Eustachian tubes. 

In laryngeal diphtheria sl steam spray or a croup kettle adds 
to the comfort of the case. Intubation or tracheotomy should 
not be put off until the child becomes exhausted from its 
dyspnea. Intubation is the operation of choice. 

In all forms of diphtheria, but especially in croup, it is well 
to keep the air of the room moist and at a temperature of about 
70° F., if this be practicable. Good ventilation of the sick- 
room must of course be carried out. The placing of disinfect- 
ants and antiseptics about the room is of no value. 

Serum Therapy. — Shortly following the discovery of 
diphtheria antitoxin the mortality of diphtheria was reduced 
from over 50 per cent to about 12 per cent (Babinsky) and the 
mortality of laryngeal diphtheria from 73 per cent to 27 per 
cent (The American Pediatric Society Report, 1897). In 
recent years, through the earlier administration of antitoxin 



502 DISEASES OF CHILDREN 

and the use of larger doses the mortality has been still further 
reduced. Antitoxin may be looked upon safely as a sure cure 
for diphtheria and "if carelessness, ignorance and inertia were 
excluded, the death-rate to-day could be zero" (Place, The 
Oxford Medicine, 1921). 

Antitoxin, as the name implies, is an antidote to the toxin 
generated by the diphtheria bacillus but it does not destroy the 
bacillus. In order to get the best effect from antitoxin, there- 
fore, it must be administered early in order to prevent the toxin 
in the blood from exerting its specific effect upon the tissues. 
If the disease has not been promptly arrested, as shown by 
the continuance of the fever and the persistence of or spread 
of the membrane a second dose must be administered. A large 
initial dose in the majority of instances arrests the progress of 
the disease, making a second dose unnecessary and is therefore 
to be advocated. 

The dosage of antitoxin is purely arbitrary and since no more 
harm can come from a large dose than from a small one it is 
better to err on the safe side and give the comparatively large 
close. The present good commercial brands of antitoxin are 
concentrated and the amount to be injected has therefore been 
reduced considerably; also, most of the serum has been removed 
and for this reason serum rashes are rarely encountered. From 
personal experience I would recommend the following doses: 

Mild cases, with purely tonsillar exudate, 5000 units. 
Moderately severe cases with extension to the pillars or uvula, 
10,000 units; severe cases with nasal involvement, 20,000 units 
given intravenously. Laryngeal cases, 10,000 units repeated 
in from six to twelve hours if necessary. 

The injection may be made subcutaneously or intramuscu- 
larly; the latter method is preferable. The best site for a sub- 
cutaneous injection is the lateral chest region below the axilla. 
Intramuscular injections may be made into the outer side of 
the thigh or into the buttocks. A prompt drop in the temper- 
ature and pulse rate together with a decrease in the faucial 



ACUTE INFECTIOUS DISEASES 503 

hyperemia is noted when sufficient antitoxin has been admin- 
istered. The membrane ceases to spread and on the following 
day it shows signs of loosening from the mucous membrane. 
If these signs of improvement do not occur, a second and 
larger dose (an additional 5000 units) should be administered. 

Homeopathic remedies are of value both for the local and 
general disturbances caused by the diphtheritic toxin. The 
red iodide of mercury is especially useful for the throat symp- 
toms ; belladonna is indicated by the fever and inflamed throat 
and should be alternated with the mercury. In the advent of 
nephritis, the bichlorid of mercury is indicated. Apis is indi- 
cated when there is much edema of the fauces. When toxemia 
is present arsenicum and rhus tox. are indicated. 

Cardiac weakness calls for stimulation ; whiskey and caffeine 
sodiobenzoate, 1 to 2 grs. hypodermically. When there is 
vomiting and signs of rapidly progressing heart failure morphia 
hypodermically is the best remedy. Nothing should be given 
by mouth and enteroclysis may be employed. 

Post-diphtheritic paralysis. — Gelsemium, causticum and 
phosphorus are the most useful remedies. Strychnia is ex- 
tensively used but without distinct benefit. The indications for 
gelsemium are paralytic weakness of the extremities, paralysis 
of the eye muscles and cardiac irregularity. Causticum and 
phosphorus present symptoms of definite nerve and cord lesions. 

GLANDULAR FEVER. 

The term "glandular fever" is used to describe a peculiar 
type of acute infection in which enlargement of the superficial 
lymph-nodes and fever are the chief clinical manifestations. 
The condition was first described by Pfeiffer in 1889 and was 
considered by' him to be a specific acute infectious disease. He 
did not, however, succeed in isolating a specific organism and 
while epidemics from various sources have been reported, still 
glandular fever is not universally recognized as a specific 
infectious disease. 



504 DISEASES OF CHILDREN 

In the epidemics which have been reported, several cases in 
a household have usually been observed. It is most frequently 
seen between the ages of two and eight years. 

Symptoms. — The onset is abrupt with symptoms suggestive 
of an upper respiratory infection, namely, fever, slight redness 
of the throat with discomfort and at times the child complains 
of a painful stiffness of the neck muscles. This symptom is 
probably due to the associated adenitis. Swelling of the 
cervical glands is the most marked clinical manifestation, the 
posterior cervical chain being chiefly involved. The swelling is 
so pronounced that the glands can be seen as well as palpated. 
They are painful to the touch but there is no redness of the 
overlying skin and suppuration does not set in. Associated 
with the cervical adenitis there is more or less general involve- 
ment of the superficial lymph nodes so that enlarged glands 
in the axilla and groins can usually be demonstrated. Enlarge- 
ment of the spleen has also been frequently noted as well as 
enlargement of the liver. In some of the more severe cases 
a transient albuminuria has been noted. 

The duration is from a week to ten days, depending upon 
the severity of the infection. No fatalities or sequelae have 
been reported. With the subsidence of the fever the glands 
gradually return to normal and abscess formation is not to 
be anticipated. 

The chief interest to be attached to glandular fever is the 
question of diagnosis. We can only accept the diagnosis of 
glandular fever in a case of acute febrile generalized adenitis 
in which an acute throat infection such as a streptococcus sore 
throat can be ruled out. Streptococci may, however, set up 
an infection of the cervical glands without leaving much evi- 
dence of their activity in the mucous membrane of the throat. 
Often the case is not seen until two or three days after the 
initial symptoms developed and the pharyngitis or tonsillitis 
which was present at that time has already subsided. The 
infection, however, is still active in the lymph-nodes which 



ACUTE INFECTIOUS DISEASES 505 

accounts for the persisting fever and glandular swelling. Acute 
cervical adenitis with high, irregular fever which may last for 
several weeks is not an uncommon condition and in these cases 
the throat may appear to be negative unless the child was seen 
at the time of onset of the infection or unless a more than 
cursory examination of the tonsils and posterior nares is made. 
Fortunately these cases usually clear up without suppuration 
as in the case of glandular fever but the temperature is more 
of the septic type and of longer duration. 

The treatment of glanduar fever is that of any other mild 
infectious disease. In the early stage the instillation of a ten 
per cent aqueous solution of argyrol into the nose may be of 
advantage. Belladonna 2x is useful at this stage for the fever, 
throat discomfort and neck symptoms. As the glands become 
swollen and sensitive mercurius solubilis 3x trituration may be 
given in alternation with the belladonna. Local applications 
to the glands are unnecessary. 



TYPHOID FEVER. 

Typhoid fever is a self limiting disease, caused by the 
bacillus of Eberth. The bacillus is found in large numbers in the 
discharges from the bowels of a patient suffering from typhoid 
fever. It can also be recovered from the spleen, liver, Peyer's 
patches and the mesenteric glands. During the first week of 
the disease, positive blood cultures may be obtained in prac- 
tically 100 per cent of all cases. The organism is, however, 
gradually destroyed in the blood stream and during the second 
week the percentage of positive blood cultures falls to about 
70 per cent and in the third week to about 30 per cent. It can 
rarely be recovered from the blood during convalescence, but at 
this time it may be still cultured from the urine and feces. In 
fact, in some patients the bacilli persist in the urine and feces 
for a long time after convalescence and such an individual con- 
sequently becomes a "typhoid carrier/' It is also believed that 



506 DISEASES OF CHILDREN 

the gall bladder may harbor the typhoid bacillus for a long 
time. 

The anatomical lesions are inflammation of Peyer's patches 
and of the solitary follicles in the ileo-cecal region with tend- 
ency to ulceration and enlargement of the spleen. A maculo- 
papular eruption of rose-colored spots appearing mainly upon 
the abdomen is one of the pathognomonic signs of typhoid fever, 
but like ulcerative lesions of the intestines it is not so con- 
stantly associated with the disease in children as in adults. The 
typhoid bacilli have been demonstrated in these spots. The 
accompanying symptoms are fever of a characteristic type; 
prostration and disturbances in the nervous system; more or 
less diarrhea and wasting. Here again it is not as typical as in 
adults. The fever is more irregular, and the duration is shorter, 
as a rule. On account of the absence of pronounced ulceration 
of the bowel in the second week, the temperature does not show 
the septic course assumed in adults at this time. This condi- 
tion, however, is not to be absolutely excluded. The associated 
symptoms are usually milder and diarrhea may not appear 
until in the later stages of the disease. There is, however, a 
severe type of typhoid fever occurring in children that may 
present every unfavorable phase of the disease as it is en- 
countered in the adult, not barring copious hemorrhages and 
perforation of the bowels, but as a rule the gravity of these 
cases depends more upon the degree of toxemia than upon 
anatomical lesions. 

Only in recent years has the fact that typhoid fever is 
common during childhood been recognized. Many mild cases 
were looked upon as a simple continued fever, while more pro- 
nounced ones received the appellation infantile remittent fever, 
or they were diagnosed worm fever. Some confusion as to the 
gravity of the disease is still to be detected in the writings upon 
this subject. My own experience leads me to the conclusion 
that we encounter both mild and grave cases of typhoid fever 
in children just as in adults, with the exception however that 



ACUTE INFECTIOUS DISEASES 507 

the mild cases predominate. Aside from this I can see very 
little difference between the disease as it occurs in childhood 
and in adult life. In infancy typhoid fever is rare and runs a 
grave course. In childhood, however, we seem to have more 
vitality and recuperative power than in adult life and the child 
stands a better chance of pulling through than an older in- 
dividual. 

Etiology. — Infection takes place through the alimentary 
tract. The commonest source of infection is drinking water 
that has been contaminated with the dejecta of typhoid fever 
patients. 

Milk is a common carrier of the infection. As the bacilli 
grow rapidly in milk, the adulteration of this commodity with 
contaminated water becomes a grave matter. A frequent cause 
of milk contamination is brought about by the rinsing of milk 
cans with polluted water or the handling of the milk by 
"typhoid carriers." The possibility of the germ entering the 
system through the inspired air is doubtful. Contagion is not 
uncommon as shown by the frequency of the disease among 
nurses. The house fly is also most likely a potent factor in the 
spread of the disease. 

Typhoid fever is rarely encountered before the second year, 
but there is no doubt that it does occur during infancy. A 
number of authentic cases are on record, and I have personally 
encountered it. In two reported epidemics of wide distribu- 
tion 1 per cent of the cases occurred in infants under two years 
old. The mortality is high in the infantile cases. 

The majority of cases are seen after the sixth year. Boys 
are more frequently attacked than girls. Epidemics are more 
prevalent in the fall than at other seasons. Modern sanitation 
has practically eliminated typhoid fever from most of our 
larger cities. 

Pathology — The pathologic lesions are not as marked as in 
the adult, and the usual explanation given for this difference in 
pathologic findings is the fact that the child's gut is still 



508 DISEASES OF CHILDREN 

anatomically immature. The first change observed in the in- 
testines is a catarrhal inflammation of the lower portion of the 
ileum, together with swelling of the solitary follicles and 
Peyer's patches in the ileo-cecal region. The cecum and colon 
are moderately involved in the catarrhal inflammation. 

As the process continues round-cell infiltration into the lym- 
phoid structure constituting the swollen follicles and patches 
takes place, with the formation of elevated placques and shot- 
like projections. The amount of infiltration, however, seldom 
attains to the degree observed in the adult, and, instead of 
necrosis from compression of the blood-vessels supplying the 
affected area setting in, it usually terminates by fatty degener- 
ation and resorption of the infiltration. For this reason the 
course is shorter and more benign, and ulceration of the bowels 
is much rarer than in adults. In older children, however, the 
same lesions are to be found that characterize typhoid fever in 
adults. With the breaking down of the infiltrated areas, deep 
oval ulcers, their long axis corresponding to the direction of the 
bowel, are found. Smaller, irregularly-scattered ulcers result 
with the breaking down of the solitary follicles. The slough is 
more frequently superficial separating without the production 
of a deep ulcer and unattended by the septic fever observed in 
adults at this stage. Grave symptoms are more frequently de- 
pendent upon toxemia than upon anatomical lesions. General 
infections without localization is also possible.. According to 
Mallory these pathologic lesions result from a specific action of 
the typho-toxin upon the endothelial cells of the blood-vessels, 
most marked at the site of the infection (intestinal submucosa). 
Cell proliferation results, these cells acting as phagocytes and 
many of them fuse and become giant cells. A secondary result 
is clogging of the capillaries with these cell clumps and in this 
way necrosis of the tissue results. 

The changes found in other organs are swelling of the mes- 
enteric glands, swelling of the spleen, which is soft and pulpy; 
parenchymatous degeneration of the heart, liver and kidneys. 



ACUTE INFECTIOUS DISEASES 509 

Hypostatic pneumonia, bronchitis of the finer tubes and bron- 
chopneumonia are commonly associated with typhoid fever. 
These lesions are usually due to a secondary infection, although 
the typhoid bacillus may incite any of these complications and 
even act as a pus producer, notably when it invades the joints or 
medullary canal. Slight pathological changes in the kidneys 
are common and severe lesions may occur. Bacilli are present 
in the urine in about 20 per cent of cases during the third and 
fourth week (Park), and the urine may become cloudy from 
their presence. 

Symptoms. — The onset of typhoid fever is gradual in the 
majority of cases being preceded for a day or two by prodromal 
manifestation, such as general malaise; headache; restless and 
dream-disturbed sleep ; anorexia and constipation. There may 
be slight chilliness recurring for several days, but rarely a de- 
cided initial chill. Nosebleed is less frequent than in adults, 
but abdominal pain is more common. The temperature now 
begins to rise in a characteristic manner. Morning remissions 
are marked, but the fever rapidly reaches its acme, usually in 
from four to five days; in adults this is not attained until the 
end of the first week, and there is a more gradual step-like rise 
in the temperature. 

At times the temperature rises abruptly instead of ascending 
gradually. This is more common in children than in adults. 
The temperature soon reaches its maximum evening rise (103 
deg. to 104 deg. F.) and by the end of the second week a rapid 
decline in the temperature is the rule in such cases. On the 
other hand, an abrupt beginning with high fever (105 deg.) 
and early delirium is characteristic of the gravest (fulminat- 
ing) form of the disease, namely, acute typhoid septicemia. 
After the acme has been attained the fever presents a contin- 
uous remitting type. The remission occurs in the morning, 
and the exacerbation in the evening ; in severe forms, with high 
temperature, the remissions are not as marked as in milder 
cases. Toward the end of the second week (about the twelfth 



510 DISEASES OF CHILDREN 

day) the morning remission becomes more pronounced, and 
soon a lowering in the evening rise is noticed. The temperature 
now falls by lysis, and in the course of from a few days to a 
week the stage of defervescence is completed. Accordingly, a 
typical, uncomplicated case of moderate severity occurring in 
a child under ten years old pursues a course of from fifteen to 
nineteen days. Severe cases, or such in which complications 
occur, run a much longer course or prove fatal. 

The age of the child apparently exerts an influence upon the 
duration of the fever. In children of iive years the average 
duration is 15.7 days; at eight years, 18.3 days, and at ten 
years 20.3 days (Montmollin). Cases of short duration how- 
ever are very likely to have reinfections and so in the end most 
typhoid fever cases run their allotted three to four weeks before 
full immunity is established. 

The symptoms occuring during the first stage are fever, 
accompanied by prostration, gastric derangement and marked 
indifference. The face is pale, and the cheeks usually flushed. 
The tongue is heavily coated, the lips dry and the breath offen- 
sive. During the second and third week the prostration and in- 
difference increase excepting when the patient becomes actively 
delirious, the lips are cracked, often bleeding; there is pallor 
and a characteristic waxy appearance of the extremities de- 
velops as a result of the poor peripheral circulation. 

The temperature is not always an index of the severity of the 
infection. While abrupt onset with early hyperpyrexia in- 
dicates an intense infection, still a weak heart and low vitality 
may be the reason for failure to react against the disease and 
consequently we may have most serious cases with moderately 
high fever. Cases are on record in which no rise of temperature 
occurred, and still grave symptoms were present. In such 
the prognosis is bad. A sudden rise of temperature during the 
course of the fever usually indicates a complication, while 
a sudden fall means hemorrhage or perforation. 

The tongue is heavily coated with a light-yellowish fur. 



ACUTE INFECTIOUS DISEASES 511 

This coating wears off in places, exposing the slightly swollen 
papillae as red specks. A red streak down the centre is likewise 
produced by the tongue rubbing against the upper central 
incisors during its propulsion. Only in severe and protracted 
cases does the tongue become brown and cracked. 

Cracking and bleeding of the lips is common in children 
because they constantly pick at the same unless restrained. 

The bowels are usually constipated in the beginning, but they 
may become loose as the fever progresses. In cases marked 
by severe bowel symptoms the stools are thin and watery; often 
involuntary. The abdomen is prominent, and tenderness and 
gurgling are found in the right iliac fossa upon pressure. This 
is due to the accumulation of fluid in the lower ileum and may 
be present even when there is constipation. Gas forms plenti- 
fully, but owing to the paretic condition of the gut it is not 
readily expelled. The typical typhoid stool is loose and of a 
dirty, yellow color, being appropriately described as the "pea- 
soup stool." It has a characteristic penetrating offensive odor, 
which may cling stubbornly to the patient. During the second 
week, when delirium sets in, the stools are often involuntary; 
this condition may remain to the end in adynamic cases. 

The eruption is not as constant and is less abundant in young 
children than in adults ; it is found upon the abdomen and lower 
portion of the chest, developing in crops. It is absent in per- 
haps 20 per cent of cases (Jacobi). The first crop appears 
about the eighth day, successive crops appearing for a week or 
longer. The spots consist of small, rose-colored macules, dis- 
appearing on pressure. They may spread to the neck and lower 
extremities, and in serious cases with septic infection petechia? 
may develop. 

The spleen becomes enlarged early in the disease; in fact 
by the end of the first week it can usually be felt at the border 
of the ribs. It may serve as an index to the progress of the 
disease, its return to normal size during the middle of the third 
week auguring a good prognosis. If it fails to diminish in 
size there will be a relapse (Jacobi). 



512 DISEASES OF CHILDREN 

The pulse furnishes valuable data for diagnosis early in 
the disease. There is a characteristic slowness about the pulse 
of typhoid fever in the first week which is not, however, as 
marked in children as in adults. Nevertheless, the pulse does 
not increase in rate to the same degree that it would be found 
in most other acute febrile conditions. With the progress of 
the fever, however, it becomes rapid and feeble. We should, 
therefore, always suspect enteric fever whenever a febrile 
condition is encountered in children in association with a 
relatively slow pulse-rate in the early stage. The opposite 
condition holds good in meningitis. The dicrotic pulse, so 
characteristic in adults, is observed only in older children. 

The disturbances of the nervous system are apathy, pros- 
tration and cerebral irritability. The child is often exceedingly 
cross and slow in answering questions and obeying requests. 
Delirium is usually present, especially during the night, and 
if the child is particularly susceptible to the typhoid poison, 
symptoms resembling meningitis may develop. Thus, dilated 
pupils, retraction of the head, twitching of the muscles of 
the face and extremities, crying out in sleep and stupor are 
frequently encountered. They disappear with the fall in the 
temperature. Cases that are very toxic may have either an 
active, excitable delirium or a low, muttering delirium, and 
twitching of the tendons, gritting the teeth and crying out 
in sleep, together with complete loss of control over the bladder 
and bowels will be noted. A true meningitis may complicate 
typhoid fever in rare instances. 

The urine may become albuminous from acute parenchy- 
matous degeneration of the kidneys ("nephro-typhus"). The 
bacillus is usually present in the urine in such cases, which 
accounts for the albuminuria. Actual nephritis is rare. Dur- 
ing convalescence the urine is usually increased although it is 
possible to incite a polyuria during the course of the fever 
by making the patient drink copiously of water. 

The blood undergoes no important changes in the early 



ACUTE INFECTIOUS DISEASES 513 

stages of the disease;- by the third week a decided anemia has 
developed, due to a reduction both in the number of red 
corpuscles and in the amount of hemoglobin. A moderate 
leucopenia with increase of the large mononuclear leucocytes 
is characteristic. Leucocytosis does not appear unless perfora- 
tion or secondary infection occurs. 

Besides the rose-spots, sudamina frequently develop upon 
the skin, mainly on the chest and abdomen. They appear in 
the later stages of the disease. At this period profuse and 
debilitating sweats may occur, with subnormal temperature. 
A subnormal temperature during convalescence is the rule. 

Bed-sores, boils, phlebitis and abscesses in various regions 
are seen in septic cases and in the debilitated. 

Abortive Type. — Instead of running its full course typhoid 
fever may abort at any stage. The child may be taken ill with 
such characteristic symptoms as nosebleed; ascending fever; 
iliac tenderness; dry, coated tongue and rose-spots, but by the 
tenth or twelfth day the temperature has reached normal. A 
positive Widal reaction verifies the diagnosis in these cases. 

Reinfection and Relapses; Recurrences. — Eeinfection 
may be said to occur in about 10 per cent of cases. It usually 
occurs during the first two weeks of convalescence, but a sudden 
rise in the temperature and a return to the original fever curve, 
together with the reappearance of symptoms, may set in during 
the latter part of the third week before the evening temper- 
ature has yet become normal. A relapse indicates a reinfection 
with germs that have escaped destruction and it is accompanied 
by the symptoms of the original attack. A fresh crop of rose- 
spots usually appears. The average duration is from ten to 
fourteen days. The symptoms are usually mild, but death may 
occur during a relapse. Kelapses are common in cases that 
have run a mild or short course and have not developed full 
immunity. One attack confers immunity for a life time and 
second attacks of typhoid fever are exceedingly rare. Usually 
a so-called second attack is one of paratyphoid fever. 
34 



514 DISEASES OE CHILDREN 

Among the complications, bronchitis and bronchopneumonia 
are the most frequent. Bronchitis is almost a constant accom- 
paniment of typhoid fever. Bronchopneumonia is not un- 
common; this complication is a frequent immediate cause of 
death in the grave types of the disease. A lobar pneumonia 
may also complicate typhoid fever. This may be due to a 
mixed infection with the pneumococcus or it may be due 
primarily to the typhoid bacillus. Otitis media; bedsores; 
circumscribed suppurative processes; phlebitis and intestinal 
hemorrhages are occasionally seen. Fatal hemorrhages and 
perforation are rare, but perhaps not as rare as is generally 
supposed. Abscess of the lung, empyema and septic parotitis 
are also among the rare complications, usually seen only in 
hospital practice. They are almost always fatal. 

Hemorrhage occurs most frequently during the third week. 
Its indications are collapse and a rapid fall of the temperature. 
Death may occur before blood is expelled. The coagula may 
be felt in the ileo-cecal region. Perforation is less common than 
hemorrhage and presents the most serious of all accidents. 
Characteristically it is preceded by sharp abdominal pain fol- 
lowed by collapse, and usually intestinal hemorrhage. The con- 
dition, however, may be masked and not suspected until perito- 
nitis develops. 

Other conditions which have been found associated are 
ulceration of the mouth, throat and genitals; peritonitis; 
suppurative synovitis and osteitis; nephritis; tuberculosis. 
Endocarditis is rare but myocardial degeneration is frequently 
found in the severe types of infection. 

Sequelae affecting the nervous system are transitory aphasia; 
multiple neuritis; chorea and insanity, all fortunately rare. 

Prognosis. — The prognosis is, on the whole, more favorable 
in children than in adults. Perhaps the chief reason for this is 
the average shorter duration of the fever, the greater tolerance 
on the part of the heart and the lesser liability of severe 
hemorrhage and intestinal perforation, but we must bear in 



ACUTE INFECTIOUS DISEASES 515 

mind that the previous health of the child and the development 
of one of the graver complications must be carefully considered 
in estimating the prognosis. In young infants the prognosis 
is grave. The mortality rate is not very uniform, thus Holt 
has placed it at 5.4 per cent; Steffen at 6.7 per cent; Henoch 
at 7.5 per cent and Baginsky at 9 per cent. 

The age is an important factor; the intermediate ages are 
the most favorable. The pulse and temperature are ordinarily 
a safe guide, but as stated above the height of the fever does 
not always indicate the degree of infection. It is, therefore, 
best to go direct to the heart, auscultating daily to ascertain 
the condition of the heart muscle. When the pulse-rate re- 
mains relatively low in comparison with the fever and its 
volume is good there is no immediate danger to be feared. A 
rapid pulse, especially when this occurs early in the disease, 
is an unfavorable omen. 

Regarding the temperature, the absolute height of the fever 
in uncomplicated cases is of prime prognostic importance. 
"With every day that the temperature retains its high range 
without interruption the danger to the patient grows" (Klem- 
perer). We can usually judge of the course that the fever is 
about to run after we have observed the case up to the end of 
the first week. It is rare for the temperature to rise above the 
point attained at this time. The duration of the fever in cases 
of abrupt onset with high fever is, as a rule, short. This does 
not, however, apply to fulminating typhoid. The daily varia- 
tions in the fever are also important prognostic points; the 
greater the daily remissions, the less destructive to the organ- 
ism will be the fever, while a continuously high fever with 
but slight diurnal variation, and one that is not influenced by 
baths, etc., offers an unfavorable prognosis. 

Complications, such as pneumonia, septic infection, hemor- 
rhage and tympanitis always render the prognosis more un- 
favorable. In the fatal cases coming under my notice there was 
present, as a rule, a grave secondary infectious condition, such 



516 DISEASES OF CHILDREN 

as septic parotitis, empyema, pulmonary abscess and osteomy- 
elitis. Acute typhoid septicemia is also fatal in the majority of 
instances. Geohegan reports a fatal case from perforation 
and hemorrhage in a child under two and a half years old. 
Diagnosis. — Aside from the pathognomonic symptoms of 
typhoid fever, viz., continued fever of a definite type, rose- 
colored spots, tympanitis with gurgling and tenderness in the 
right iliac fossa, enlarged spleen and pea-soup stools, there is 
at our command the blood test of Widal and the urinary test 
(diazo-reaction) of Ehrlich. Unfortunately for the general 
practitioner, the former is difficult to carry out, requiring 
special laboratory facilities and expert technique in bacter- 
iology. In every large city, however, there are pathological 
laboratories where this test can be made so that it is rarely 
necessary for the physician to be especially equipped. Widal's 
test consists of the introduction of a few drops of blood from 
a patient suffering with typhoid fever into a pure culture of 
typhoid bacilli. A microscopical examination reveals a prompt 
formation of clumps consisting of the agglutinated bacilli, 
which have also lost their motility. The reaction is one of 
infection and immunity, indicating that a toxic substance has 
been formed in the blood serum, which is capable of destroying 
the motility of the germs causing the disease, and also inducing 
their agglutination. Dried blood drops, collected on unglazed 
paper, may be used for the test. In dilutions of 1 to 40 or 50 
with fresh bouillon cultures of typhoid bacilli the characteristic 
reaction may be obtained. The Widal reaction may be ob- 
served on the fourth day of the disease, but it is usually 
delayed until the eighth day. It continues throughout the 
fever and may persist for some time after the recovery. 

The frequently-recorded negative results should not weigh 
heavily against this most valuable diagnostic adjuvant, as faulty 
technique is probably more to be blamed than the test itself. 
The proportion of cases in which a definite reaction occurs and 
the time of its appearance, based on an extended Health Depart- 



ACUTE INFECTIOUS DISEASES 517 

ment Laboratory experience, is given by Park as follows: 20 
per cent gave positive results the first week, 60 per cent in the 
second week, 80 per cent in the third week, 90 per cent in the 
fourth week. In 88 per cent of the cases in which repeated 
examinations were made (hospital cases) the reaction was found 
at some time during the fever. Its late appearance, usually not 
before the eighth day, renders it less valuable than blood 
cultures as an early sign. 

The diazo-reaction is a valuable corroborative test, but it is 
also obtained in acute miliary tuberculosis and in rapidly 
progressing pulmonary tuberculosis. In fact, a large number 
of infectious conditions will give this reaction, notably measles. 
Cases without intestinal localization will present difficulties 
in diagnosis. In such, only a bacteriological examination of the 
blood will solve the problem. Many of the acute typhoid 
septicemias are of this character. They present the picture of 
a profound toxemia with high fever and early delirium. Death 
may occur before it is possible to reach a diagnosis, and the 
post-mortem findings may be entirely negative (Osier). 

From malarial fever it can be differentiated by means of a 
blood examination to ascertain the presence or absence of the 
malarial parasite, and by the temperature curve. 

Meningitis. — ; A strong point of difference between men- 
ingitis and typhoid fever is the behavior of the pulse. In 
typhoid fever it is relatively slow in the beginning, becoming 
rapid toward the end of the disease; in meningitis the pulse 
rises proportionately with the fever in the beginning, but 
becomes slow and irregular towards the close of the case. 
Furthermore, in meningitis the abdomen is retracted, the 
bowels are constipated throughout, and paralyses of the cranial 
nerves are to be observed. The reflexes are exaggerated, and 
Kernig's sign may be elicited. None of these symptoms are 
present in typhoid fever. Contraction of the flexors of the 
legs may develop in protracted cases of typhoid fever as a result 
of nutritional disturbances of the muscles or possibly a neuritis 



518 DISEASES OF CHILDREN 

but this should not be confused with the Kernig sign. Menin- 
geal irritation is common, but true meningitis is very uncom- 
mon. In typhoid fever of the cerebro-spinal type, it may be 
necessary to resort to lumbar puncture before a positive diag- 
nosis can be made. 

Acute miliary tuberculosis may present difficulties in differ- 
ential diagnosis. Aside from the absence of the Widal reaction 
in tuberculosis there is a more rapid pulse and greater irregu- 
larity in the course of the fever. Often the "inverted type" 
of fever is noted. The spleen is less likely to be enlarged 
than in typhoid fever. The most characteristic sign of miliary 
tuberculosis, however, is rapid respirations and cyanosis, more 
or less pronounced. An old tuberculous lesion may be demon- 
strable. Meningitis is commonly associated. The most difficult 
cases to differentiate are those in which abdominal symptoms 
are the predominating feature. 

Early pronounced localization of the infection in some other 
system than the intestinal tract may lead to confusion. As 
Osier emphasizes, the brunt of a very acute infection may 
fall upon the cerebro-spinal, the pulmonary, or the renal 
system. Typhoid lesions in the appendix may lead to a 
suspicion of appendicitis. The fact, however, that malaise and 
fever have preceded the development of the iliac tenderness 
should throw out the diagnosis of appendicitis which begins with 
general abdominal pains followed by vomiting, then appen- 
dicular tenderness, rigidity of the right rectus muscle and 
lastly fever and rapid pulse. 

Treatment. — The patient should be put to bed in a room 
that can be thoroughly ventilated, and one from which all 
unnecessary furniture and draperies have been removed. Pro- 
vision must be made for the disinfection of the stools and urine, 
which can be accomplished by the use of an active germicide. 
A strong solution of chloride of lime, Piatt's chlorides, or 
carbolic acid (5 per cent solution) is to be poured over the stools 
as soon as they are passed, and allowed to act upon them for 



ACUTE INFECTIOUS DISEASES 519 

several hours before they are emptied into the water-closet. 
All towels, napkins and sheets soiled by the patient should be 
boiled in order to render them sterile. 

The diet is of the greatest importance. Owing to the in- 
testinal lesions, solid food must be withheld until at least a 
week after disappearance of the fever, diarrhea and abdominal 
tenderness. Where abdominal symptoms have been pronounced 
during the fever, it is better to wait even longer before resum- 
ing solid food. Iu the milder class of cases we may return to 
semi-solid food on the fifth day after the temperature has 
ceased to rise above 100 deg. F., gradually returning to solid 
food. Such articles of diet as thoroughly cooked cereals; 
poached eggs; milk toast; the soft portion of a baked apple; 
baked potato, etc., should be selected at this time. 

Of late there has been a decided reaction against the strict 
dieting of the typhoid fever patient and semi-solid foods are 
prescribed by many clinicians during the height of the fever. 
While this is permissible in adults especially when the patient 
is hungry and not delirious I find that children do much better 
on a restricted diet. The chief foodstuff which they require to 
maintain nutrition and avert dangerous destructive tissue 
changes is carbohydrate and this can be added to the milk and 
thus given in liquid form. By this means we also supply a 
large amount of water which is one of the most important agents 
in the treatment of the disease. 

Although milk is looked upon as an ideal liquid food, still 
it does not act as such in many cases, and, when given unmodi- 
fied, may pass through the bowels in firm curds. The stool 
should, therefore, always be inspected when administering 
milk, as such curds may induce most unfavorable symptoms. 
A notable ill-effect of milk observed in some patients is tympan- 
itis; this promptly disappears when the milk is discontinued. 
In young children it is always best to dilute the milk with 
barley-water or boil it and add sugar of milk or a maltose pre- 
paration. 



520 DISEASES OF CHILDREN 

Strained vegetable soup, is a most valuable food, and an 
agreeable change for the patient. Cream may be added to the 
soup. In the absence of diarrhea grape juice is permissible. 

It is always best to increase the caloric food value of the 
milk by adding to it sugar of milk, Dextrimaltose, or Mellin's 
Food. In case of diarrhea the milk should be boiled. Ice 
cream, junket, gelatin and cup custard may usually be given 
during the febrile period. The best results are obtained by 
selecting the food best adapted to the case, and administering 
six to eight ounces every three hours. Some variation in the 
character of the diet is most agreeable to the patient and a great 
aid in keeping up the nutrition. The patient should also receive 
water freely. 

The child must be sponged daily with cold or tepid water 
and when the fever runs high, remaining above 103 deg. F., 
during the greater period of the twenty-four hours, these baths 
may be repeated every three hours. After the bath the body 
should be vigorously rubbed, especially the extremities, until 
a good reaction sets in. An alcohol rub after the sponge bath 
usually induces a good reaction. Rubbing the body briskly 
with pieces of ice wrapped in a towel will have a most grateful 
and beneficial action in cases of hyperpyrexia. Should the 
patient react poorly after any form of cold water treatment it 
is better to desist and use milder measures, such as the tepid 
sponge bath or the pack, beginning with luke-warm water and 
gradually reducing the temperature of the pack to 85 deg. F. 
A Turkish towel wrung out of water of the proper temperature 
and wrapped around the body of the child makes an excel- 
lent pack. 

In cases that are profoundly toxic I have employed the 
Murphy drip with good results. An enema should first be given 
and then the normal salt solution permitted to flow into the 
rectum at the rate of sixty drops per minute for two to three 
hours, and repeated after a two hour interval. Dextrose may 
be added in amounts of from frve to six per cent. 



ACUTE INFECTIOUS DISEASES 521 

Stimulation may become necessary in the later stages of the 
fever. The first and most prominent indication is cardiac 
weakness. Daily auscultation of the heart should be practiced 
and when the first sound loses its muscular element and re- 
sembles the second sound (embryocardia), small doses of 
whiskey may be given. Collapse will call for hot coffee, either 
by mouth or by rectum or camphorated oil subcutaneously. 

Hemorrhage, if slight, requires nothing more than temporary 
withdrawal of food followed by greater caution in feeding, 
absolute quiet of the patient and possibly a change of remedy. 
When severe, it proves a grave complication. A cold appli- 
cation to the abdomen in the form of Leiter's tubes or an ice 
bag will prove of great benefit. Absolute rest must be enjoined, 
even the bed pan may be put aside and clothes used to collect the 
excreta. A blood transfusion is necessary if the loss of blood 
has been great. 

Perforation and peritonitis are extremely fatal complications, 
although early laparotomy in perforation before peritonitis has 
set in offers better hope for the patient than conservatism ac- 
cording to the observations of Finney and Keen. 

The leading typhoid remedies are baptisia, bryonia, gelse- 
mium and rhus tox. The selected remedy should be continued 
throughout the entire course of the disease unless positive in- 
dications for a change occur. 

The following indications embrace the most important symp- 
toms of the leading remedies at our command. 

Agaricus' — In typhoid fever where the nervous symptoms 
predominate. Low fever, tremulous tongue, and general tremor 
of the entire body. Among adults it is recommended for drunk- 
ards in whom the heart is giving out. Alcoholic stimulants 
must, of course, not be withheld from such cases. We often 
encounter boys who smoke cigarettes excessively and whose 
nervous system is about as wretched as the adult drunkard's. 
Here agaricus is well indicated. 

Arnica. — General stupefaction of the senses; general sore- 



522 DISEASES OF CHILDREN 

ness, bed feels too hard; the sleep is disturbed by anxious 
dreams ; the tongue is red and dry, with a brown streak down 
the centre; putrid taste in mouth; fetor ex ore; involuntary 
discharge of feces and urine ; the extremities become cold while 
the head remains hot; hemorrhages and bedsores develop. 

Arsenicum. — Low types of typhoid, usually the later stages 
in unfavorable cases. Farrington cautions against the early 
use of arsenic in typhoid fever, and considers it a remedy 
capable of doing harm unless clearly indicated. It is most 
useful in the young or aged, or in those debilitated by previous 
ailments. The general symptoms so characteristic of arsenic, 
such as great restlessness, prostration; thirst for small quan- 
tities of water ; hot, dry skin ; general aggravation of all symp- 
toms soon after midnight or noon ; cadaverous smell of the dis- 
charges as well as of the patient, are all prominent indications 
for its use. 

Baptisia. — The well-known mental symptom, the hallucina- 
tion that the body is dismembered, that certain parts of the 
body are double, or that there is a second self in the bed with 
the patient, is a strong indication for baptisia, although its ab- 
sence by no means deprives this drug of its usefulness in 
typhoid fever. Phosphorus and petroleum both have similar 
symptoms. The condition calling for baptisia is characterized 
by great weariness and a bruised feeling of all the limbs, to- 
gether with a low type of fever and physical prostration ; offen- 
sive diarrhea ; breath, sweat and urine are alike offensive ; there 
is dull stupefying headache; the patient is delirious, sleeps 
heavily and is aroused with difficulty. The tongue is dry and 
brown, the conjunctivae are injected; the face is flushed and 
presents a besotted expression ; exhaustion is marked. Baptisia 
may be indicated early in the disease when the symptoms are 
intense from the beginning. 

Bryonia. — Bryonia may be indicated at any stage, although 
its most frequent application will occur during the first stage. 
The symptoms calling for its selection are very characteristic 



ACUTE INFECTIOUS DISEASES 523 

and prominent — irritability, lassitude, desire to remain quiet 
and sleep; headache, worse from opening the eyes or moving 
the head ; dryness of the lips, mouth and throat, with thirst for 
large quantities of water; aching of the limbs, worse from 
motion; frequent brown, putrid stools; delirium at night and 
restless sleep, disturbed by dreams of daily affairs ; wants to go 
home ; visions when closing the eyes. 

Carbo veg. — Carbo vegetabilis is indicated in extreme cases. 
Many writers speak very highly of this remedy, but personally 
I am not able to say what carbo vegetabilis will do, as in such 
a condition I feel called upon to resort to stimulation and other 
adjuvant measures. 

Gelsemium. — In the early stages gelsemium is frequently 
indicated on the symptoms of lassitude, drowsiness, dull head- 
ache, with heaviness of the eyelids and photophobia; slow, in- 
termitting pulse, accelerated from slight exertion ; chilliness up 
and down the spine; epistaxis; catarrhal condition of the eyes 
and respiratory tract; diarrhea. 

Hamamelis. — Hemorrhages of dark, fluid blood from the 
bowels, with great soreness of the abdomen. 

Hyoscyamus. — The delirium indicating hyoscyamus is char- 
acterized by loquacity, obscene actions, or even attempts at 
violence. The patient picks at the bed-clothes and grasps at 
flocks in the air, with continual muttering. Stramonium is 
similar, but the loquacity is confined to one subject and the 
patient is more noisy, often crying out in terror from supposed 
visions of horrible animals, bugs, and the like, which he sees 
coming out of the floor, crawling along the ceiling, etc. Hy- 
oscyamus also has a total loss of consciousness, with dry tongue, 
involuntary stools, subsultus tendinum, dribbling of urine. I 
have seen small doses of hyoscine hydrobromate (1-1000 gr.) 
quiet a delirious patient after opium preparations had failed 
to exert any influence upon the condition. 

Lachesis. — The lachesis patient, similar to the condition 
noted under hyoscyamus, is also loquacious, but he jumps from 



524 DISEASES OF CHILDREN 

one subject to another in an incoherent manner ; there is stupor, 
dropping of the lower jaw; dry, red, or blackish tongue which 
is red at the tip and bleeding, and trembles on being protruded ; 
the stools are horribly offensive, the abdomen sensitive to touch, 
and all symptoms are more intense after sleep. Purpuric spots 
on various parts of the body. 

Mercurius. — The characteristic nocturnal aggravation, the 
greenish-yellow stools; broad flabby tongue and drowsiness may 
indicate mercurius. 

Muriatic acid. — Low types of typhoid fever, in which the 
patient is stupid, sliding down to the foot of the bed ; the tongue 
is parched and dry, difficult to protrude; stools involuntary 
while passing urine; loud moaning during sleep, and when 
awake not fully conscious of his surroundings. 

Opium. — Either complete loss of consciousness with loud, 
stertorous breathing, contracted pupils, face dark red and 
bloated or pale with death-like expression, drooping of the lower 
jaw, hot sweat, or delirium with sleeplessness due to hyper- 
esthesia of the special senses, so that slight noises keep him 
awake. 

Phosphoric acid' — Low typhoid state, in which the patient 
becomes totally indifferent to his surroundings. He can be 
aroused, but with difficulty, and soon relapses into his apa- 
thetic condition. There is great debility, rattling of mucus in 
the chest, rumbling in the abdomen, tympanitis, grayish watery 
stools, bleeding from the nose, red streak down centre of tongue, 
milky urine, clammy skin. 

Rhus tox. — After bryonia and gelsemvum, rhus toxicoden- 
dron frequently follows. The provings of rhus tox. present a 
typical typhoid state, and the anatomical changes in the in- 
testines closely correspond to the lesions of typhoid fever. The 
symptoms are sharp and well-defined, as is the case with 
bryonia. The mind becomes beclouded and the mental opera- 
tions are performed with difficulty. The patient is restless 
from a distressing aching in every limb, and constantly changes 



ACUTE INFECTIOUS DISEASES 525 

his position to gain relief (not as in arnica, where there is sore- 
ness produced by lying in one particular attitude, which makes 
him seek a new position). The sleep is restless, disturbed by 
dreams of great physical exertion. The lips are brown and dry, 
and the teeth are covered with sordes; the tongue is likewise 
brown and dry, presenting a triangular red tip. The diarrhea 
is worse during the night, often involuntary during sleep. 

VARIOLA; VARIOLOID. 

Variola, or small-pox, is an acute infectious, highly conta- 
gious disease, characterized by fever of a typical course, 
vomiting, intense lumbar pains, and an eruption of papules 
passing through the stages of vesicles, pustules and crust 
formation, the vesicles being umbilicated. 

The nature of the contagion has not been determined. It 
is contained in the secretions, excretions and exhalations of 
the body, being especially disseminated by means of the dried 
scales and contents of the pustule. Pfeifer and others have 
constantly found small, homogeneous bodies in the epithelial 
cells surrounding the lesions. One or two are usually found 
in the cell substance. They probably belong to the class of 
protozoa (Park). 

It attacks all ages, from the fetus in utero to the aged. A 
case came under my notice in which the eruption appeared in 
a new-born infant on the fifth day. During the last three 
weeks of her pregnancy, the mother had had an attack of 
varioloid, which was overlooked at the time on account of its 
mild nature. The infant died on the twelfth day. Among 
children it proves especially fatal. One attack protects against 
another, at least for a long period of time. The period of 
incubation is from nine days to two weeks. 

The pock first consists of an area of round-cell infiltration 
into the rete mucosum in which a central area of coagulation- 
necrosis takes place. Inflammatory reaction occurs around this 
area, which represents the central depression of the vesicle, 



526 DISEASES OF CHILDREN 

with the formation of a reticulated vesicle containing serum, 
leucocytes and fibrin filaments. Pustule-formation supervenes, 
the leucocytes and cells of the rete mucosum becoming necrotic. 

Symptoms. — The invasion is marked by a severe chill or 
repeated chills, with rapidly rising temperature. In children, 
convulsions are common at this period. Vomiting and intense 
backache are accompanying symptoms. In some epidemics the 
initial stage is marked by an erythematous eruption, either 
diffuse or measly, or by hemorrhagic exanthem which consists 
of extremely small punctate, closely aggregated pin-head sized 
hemorrhages into the epidermis. The temperature rises on the 
first day to 103° to 104° F., continuing with slight morning 
remissions until the evening of the third day when it reaches 
its highest point. On the fourth day it falls several degrees, 
this remission lasting until the seventh or eighth day, when 
there is a secondary rise — the suppurative fever. 

The stage of eruption commences on the evening of the third 
day. Little red spots first in the face. If very numerous they 
coalesce, like measle-spots, with which they might be confound- 
ed if it were not for the granulated, shotty feel which they 
present to the sense of touch. 

The eruption rapidly spreads to other portions of the body, 
and on the third day the papule is converted into a clear 
vesicle presenting an umbilication at its summit. The vesicle 
is also loculated. In the course of a few days (eighth day of 
the disease) the vesicle is transformed into a pustule, which 
dries up after a few days or breaks down, with the formation 
of a soft, yellow crust, later becoming brownish and dropping 
off, leaving a somewhat elevated spot which in time disappears. 
This occurs where the lesions are discrete and where the process 
has not extended into the deeper layers of the skin. Where, 
however, the deeper structures have been involved they adhere 
for a long time, leaving an uneven scar, which at first looks 
pink, but by degrees grows conspicuously white, producing 
the characteristic pock marks which are permanent. 



ACUTE INFECTIOUS DISEASES 527 

Simultaneously with the appearance of the eruption upon 
the skin, identical lesions develop upon the mucous membranes 
exposed to the external air. Here it may result in great 
destruction of tissue. 

Small-pox may run its course as a discrete, confluent, hem- 
orrhage, gangrenous or malignant variety. The modified 
variety occurring in those partially protected by vaccination, 
and running a mild course without secondary fever, is described 
as varioloid. In every other respect it is identical with true 
small-pox. 

The prognosis, excepting in varioloid, is always grave. As 
complications may be mentioned bronchopneumonia, pleurisy, 
septicemia, ulcerating keratitis, suppurating otitis, arthritis. 

The diagnosis is often rendered difficult by the primary 
erythematous eruption. The true eruption may be confounded 
with measles in its early stages, but the sensation of balls of 
shot under the skin imparted to the finger by the papules of 
small-pox is a pathognomonic distinction, beside the severe 
initial symptoms of the attack. Again, in measles the temper- 
ature rises to its acme with the appearance of the rash, while 
in small-pox there is a temporary drop in the fever as the rash 
comes out. 

From varicella it is distinguished by the intensity of its 
symptoms. Moreover, the eruption appears later than in vari- 
cella, does not come out in crops, is distinctly umbilicated, and 
presents a well defined inflammatory areola. The eruption of 
small-pox is also decidedly harder and more palpable than that 
of varicella. 

Treatment. — As small-pox is one of the most serious and 
most dreaded of all contagious diseases, every precaution to 
prevent a spread of the same must at once be instituted when 
we are confronted by a suspicious case. The most rigid iso- 
lation and disinfection, as described under scarlet fever, must 
be carried out to the letter. Besides this every person in the 
house not recently successfully vaccinated (within four years) 



528 DISEASES OE CHILDREN" 

should immediately undergo the operation. The patient must 
have as much fresh air as possible. If the fever is very high 
sponge-baths are indicated. Osier {Practice of Medicine) has 
come to the conclusion that the prevention of pitting is really 
not within the power of the physician. Protecting the ripening 
papules from light and keeping the hands and face covered with 
lint soaked in cold water or mild antiseptic lotions, is, however, 
to be recommended. The red-light treatment exerts no in- 
fluence over pustulation (Schamberg). In the later stages we 
should aim to prevent the crusts from becoming hard and dry 
by the free application of vaseline. The addition of a little 
carbolic acid or boric acid to the vaseline is a distinct advantage. 

In the early stages, aconite, hell., bry., gelsemium and rhus 
tox. are to be recommended. Jahr (Therapeutische Leitfaden) 
began all cases with variolinuon as soon as the diagnosis could 
be established; and if, in spite of this remedy, the course be- 
came a grave one he followed with sulphur. He preferred 
these two remedies to all others. 

Vaccininum is spoken of favorably by Goodno and others. 
From a limited personal experience with small-pox I have come 
to look upon bryonia followed by rhus tox. as the treatment 
most likely to exert a favorable influence over the disease. In 
the stage of suppuration when toxemia sets in cinchona tincture 
and whiskey should be freely used. When collapse threatens it 
may become necessary to resort to strychnia. 

VACCINIA. 

Vaccinia, or cow-pox, is an eruptive disease of the cow, the 
virus of which produces a lesion resembling the pustule of 
small-pox when inoculated into a human being. A specific 
organism has not been isolated from the vaccinia pustules nor 
is the true nature of the disease understood, some considering 
it a primary disease of the cow, while others believe it to be 
small-pox modified by its passage through animals. It has been 
experimentally demonstrated that children vaccinated with 



ACUTE INFECTIOUS DISEASES 529 

cow-pox were not susceptible to inoculation with small-pox 
virus, the reverse condition also holding true. Pfeiffer and 
others have found small homogeneous bodies in the epitelial 
cells surrounding the lesions of both small-pox and vaccinia, 
and as small-pox virus has produced in cattle a disease indis- 
tinguishable from cow-pox, there is hardly any doubt that the 
two are due to the same micro-organism, modified by its trans- 
mission through the cow (Park). 

A successful inoculation with vaccinia affords protection 
against small-pox in the majority of cases, at least for a num- 
ber of years. Small-pox occurring in those who have been 
vaccinated usually assumes a mild course, i.e., varioloid. As 
to the modifying influence of vaccinia upon small-pox already 
in progress there is a difference of opinion. According to 
Marson, if a person exposed to small-pox be vaccinated within 
four days, small-pox will be prevented; if later, but early 
enough to allow the vesicles to reach the stage of areola, the 
attack of small-pox will be modified; but later than this it is 
useless. Curschmann opposes this view as erroneous. It is 
interesting to know the views expressed by Hahnemann on this 
subject, which are no doubt borne out by the most trustworthy 
clinical testimony — "It is well known that when variola is 
added to cow-pox, the former, by virtue of its superior intensity 
as well as its great similitude, will at once extinguish the latter 
homeopathically and arrest its development. Cow-pox, on the 
other hand, having nearly attained its period of perfection, 
will, by its similitude, lessen to a great degree the virulence and 
danger of a subsequent eruption of small-pox, for which we have 
the testimony of Miihry and many others" (Organon). 

The operation of vaccination consists of the introduction of 
the lymph from the vaccine vesicle of heifers into the circula- 
tion by bringing it in contact with a scarified surface for a suffi- 
cient length of time to permit of its absorption. Having 

cleansed the site of inoculation (usually the left arm, just below 
35 



530 DISEASES OF CHILDREN 

the insertion of the deltoid muscle) with soap and water, fol- 
lowed by scrubbing with alcohol or ether, a few parallel 
scratches about half an inch in length are made with a sterilized 
needle, just deep enough to break the epidermis and expose the 
rete mucosum. A drop of glycerinated vaccine lymph, this 
being the most reliable and aseptic form in which the virus can 
be obtained, is placed upon the scarified surface and rubbed in 
gently with the needle. Guest {Pediatrics, Vol. IX, No. 5) 
has arrived at the conclusion that the entire contents of a tube 
is too large a quantity of lymph for the average child, judging 
from the results obtained in four hundred cases vaccinated by 
this method, in which there was more pronounced inflammatory 
reaction and more glandular swelling, besides the formation of 
a larger scab than in his former cases inoculated with points. 
Personally I have found that a single scratch, about one quarter 
of an inch in length and just deep enough to expose the rete 
mucosum is sufficient for a successful vaccination and lessens 
the danger of a severe "take" and of infection. After the 
lymph has been rubbed into the scarification a period of ten 
minutes should be permitted to elapse before applying a 
dressing. 

Symptoms. — During the first three days after the operation, 
nothing excepting a slight local irritation, soon subsiding, will 
be noticed. On the third day, however, a papule appears at the 
site of inoculation, surrounded by an areola ; this papule is con- 
verted into an umbilicated vesicle on the fifth or sixth day. 
The vesicle attains its maximum development by the eighth day, 
after which it becomes pustular. The areola gradually in- 
creases in size and depth of color until this time, but disappears 
as the acute symptoms subside. The pustule then dries up, 
forming a scab. On the twenty-first day the scab comes off, 
leaving the characteristic deep, pitted scar. 

The constitutional symptoms accompanying vaccinia are 
fever, malaise, anorexia, etc., which begin with the formation 
of the vesicle, and attain their height at the period of pustula- 



ACUTE INFECTIOUS DISEASES 531 

tion, after which they rapidly disappear. Swelling of the axil- 
lary glands is usually present. 

Variations from the above-described course frequently occur. 
The vesicle may be late in developing or it may be premature 
and not fully developed in individuals who have been pre- 
viously vaccinated. A generalized pustular eruption may 
accompany the primary lesion, which may persist in recurring 
attacks after healing of the same; or complications, notably 
erysipelas, ulceration and sloughing, glandular abscesses and 
septicemia, may develop as the result of faulty technique. 
Vaccinia may also occur as a general eruption of papules, which 
turn into vesicles and pustules. They appear on the face and 
extremities about the fifth day. I have also encountered a 
general papular rash occurring on the tenth day, looking like 
measles or the early stage of small-pox. 

Deaths have occurred, but they were almost invariably from 
avoidable causes, as Voigt shows in his statistics. There is 
always a risk, however, in vaccinating a delicate, sickly child, 
and the operation should never be performed when an acute 
disturbance is present, or if there is a case of contagious dis- 
ease in the family to which the child has been exposed. I 
have observed some anti-vaccinationists vaccinate, and their 
careless method has convinced me that they had good cause 
to be dissatisfied with their practice. 

Besides, the invaccination of syphilis (when humanized virus 
was used) has occurred, and claims have been made that tuber- 
culosis was likewise transmitted. This, however, has not been 
proved. 

The age at which children are vaccinated is usually the third 
month, in the absence of any acute or constitutional illness. 
In the absence of an epidemic of small-pox I do not see the 
necessity for so prompt a procedure, especially if the infant is 
not in a good condition or is suffering with eczema. The ad- 
vantages of early vaccination are that the general symptoms are 
usually milder and there is less danger of a secondary infection. 



532 DISEASES OF CHILDEEN 

Some physicians, believing in the efficacy of vaccination to 
control whooping-cough, keep it in reserve to be employed as 
the opportunity manifests itself. All children, however, should 
be vaccinated before they are sent to kindergarten or school, 
and revaccinated at the period of puberty, or on the occurrence 
of an epidemic of small-pox. 

Treatment. — The vaccinia lesion should be cleansed daily 
with alcohol, dusted over with boric acid powder and protected 
by a gauze dressing instead of a shield. When general symp- 
toms occur one of the following remedies should be admin- 
istered. Belladonna is indicated if fever, headache, diffuse 
redness and swelling about the site of eruption and glandular 
swelling develop. Apis or rhus may be indicated by erysipela- 
tous manifestations. If there is much soreness with purulent 
secretion hepar sulph. should be given, or if the scab separates 
with suppuration and an unhealed ulcer remains, silica. I 
firmly believe that when vaccination is carried out on strictly 
aseptic lines, and the child is watched throughout as in the 
case of any other illness — being put to bed if necessary, and 
carefully prescribed for— none of the many complications and 
so-called constitutional after-effects, attributed to vaccination, 
will follow. 

VARICELLA. 

Varicella, or chickenrpox is an acute infectious disease char- 
acterized by the eruption of delicate discrete vesicles, which 
appear in crops, and disappear, in the course of a few days, by 
desiccation. 

The specific virus has not been isolated, but it is known to 
exist in the vesicles, and can be transmitted by innoculation. 
The usual manner of contracting the disease is through con- 
tact with a case, although a third person may carry the infec- 
tion. One attack protects against another. It may occur 
sporadically or epidemically. The period of incubation is 
usually two weeks. 



ACUTE INFECTIOUS DISEASES 533 

The symptoms are slight in the majority of cases, but occa- 
sionally a severe type is encountered with extensive eruption, 
high fever and corresponding constitutional symptoms. In rare 
instances such complications as bronchopneumonia, nephritis 
and meningitis may occur. The chief clinical interest however 
attached to varicella is its superficial resemblance to small-pox 
and especially to varioloid. 

The onset is abrupt, as a rule, the first signs of the disease 
being the appearance of papules and vesicles upon the trunk 
and extremities, accompanied by slight fever, anorexia, coated 
tongue and languor. Constitutional symptoms may be so slight 
as to attract no attention. Each day a new crop of vesicles 
makes its appearance; this usually continues for three or four 
days. 

The eruption appears first as a small, red, slightly papular 
spot which is soon transformed into a clear, pearl-like vesicle. 
The vesicles are unilocular, although at times they give the 
appearance of being multilocular when they involve a hair 
follicle or sweat gland. They are surrounded by a faint areola, 
and do not become pustular unless infected by scratching, etc. 
In the course of a few days they dry up, the crusts soon falling 
off without leaving a scar, although in some cases a circular, 
pale area is left, which persists for some time, or, if ulceration 
has taken place as a result of infection quite a conspicuous 
scar may remain. 

Varicella gangrenosa is a type of varicella which is attended 
by gangrenous stomatitis, as a result of infection in poorly-nour- 
ished or tuberculous children. If the process becomes extens- 
ive, it may prove fatal. As complications — which, however, are 
fortunately rare — may be mentioned erysipelas, adenitis, cellu- 
litis, gangrenous dermatitis and nephritis. A hemorrhagic 
type of varicella is also occasionally seen in which purpuric 
spots about a quarter of an inch in diameter may be the initial 
lesion. The discoloration persists for a long time after the 
vesicles have dried up. It is not uncommon to have varicella 



534 DISEASES OF CHILDREN 

and one of the other infectious fevers occur simultaneously, 
although the error must not be made of considering those cases 
of varicella beginning with an erythematous or measle-like 
rash as cases of varicella plus scarlet fever or measles. 

Diagnosis. — Varicella is to be differentiated from small-pox 
by the slight constitutional disturbances accompanying the 
rash, which appears abruptly, coming out in crops, and soon 
disappears by dessication, without pustulation or scar-forma- 
tion. The eruption of small-pox may not always come out at 
once, and frequently new papules and vesicles will continue to 
appear for several days after the first lesions were seen. They 
do not, however, erupt in distinct crops, nor do we find lesions 
in the various stages of development, that is, fresh papules and 
vesicles interspersed among pustules, as is to be observed in 
varicella. Again, the papules of varicella lack the shot-like 
feel characteristic of the small-pox lesion, and the vesicles are 
more delicate and present a characteristic pearl-like appearance. 
There is no secondary fever in varicella. If the vesicle has not 
dried up by the fourth day, it is more likely small-pox or vario- 
loid than varicella. The presence of a vaccination scar of 
recent origin is also presumptive evidence against small-pox. 

Treatment. — In the presence of fever, rest in bed, a light 
diet, and, when there is much itching, the use of a dusting- 
powder, or olive oil and boric acid, is about all that is required 
in mild cases. Aconite may be called for in the beginning, to be 
followed by rhus tox. The gangrenous or pustular variety will 
call for arsenicum, mercurius, rhus tox., etc. 

PERTUSSIS. 

Pertussis, or whooping-cough, is an acute infectious disease 
characterized by the presence of a paroxysmal suffocating cough 
and an associated catarrahal inflammation of the upper respi- 
ratory tract. It occurs both epidemically and sporadically, in- 
fection taking place through contact ; seldom through the agency 
of a third person. The virus is disseminated by droplet infec- 



ACUTE INFECTIOUS DISEASES 535 

tion during a coughing paroxysm or it may be conveyed by the 
sputum of an infected child. The specific bacilli disappear 
from the sputum after the third week and isolation of the case 
is unnecessary after that time. 

Pertussis usually occurs epidemically in the spring and sum- 
mer months although individual cases may be seen at any time 
of year. In recent years it has apparently become milder and 
more endemic in character. About 80 per cent of all cases 
occur in children under five years of age. A natural immunity 
is observed in about 30 per cent of the children exposed to the 
disease. The period of incubation is from three to eight days. 
One attack confers lasting immunity in most individuals. 

Etiology. — Pertussis is caused by the bacillus pertussis of 
Bordet and Gengou. This organism may be isolated from the 
sputum collected at the end of a coughing attack by inoculating 
a plate of blood-agar medium with the same and incubating for 
forty-eight hours. The organism grows in minute, discrete, 
elevated colonies surrounded by an area of lightened blood. 
Morphologically it is a small bacillus resembling the influenza 
bacillus. 

The pathological processes accompanying whooping-cough 
are catarrhal inflammation of the larynx, particularly in the 
region of the interarytenoid cartilages; tracheitis and more or 
less bronchitis; swelling of the bronchial glands; rhinitis. In 
fatal cases bronchopneumonia with emphysema and areas of 
atelectasis are the most common lesions found; there may also 
be entero-colitis and cerebral congestion, with effusion and 
cortical hemorrhages. The toxin of whooping-cough in some 
cases appears to affect the smaller blood-vessels and favor hem- 
orrhagic extravasations, either spontaneous or as a result of the 
congestion which is associated with the cough-paroxysm. 
Moebius believes that the nervous system may also be acted upon 
by this toxin in a manner somewhat similar to the action of the 
diphtheria toxin. 

Symptoms. — The course of whooping-cough is in three 



536 DISEASES OF CHILDREN 

stages: the premonitory, or catarrhal; the paroxysmal stage, 
and the stage of decline. The first stage usually lasts one to 
two weeks ; the second stage may persist for a month, while the 
stage of decline is a gradual lessening of the number and sever- 
ity of the coughing spells and persists as long as there is any 
bronchitis present. The duration, therefore, depends to some 
extent upon the child's general condition, the severity of the 
attack and the presence of complications. Even after apparent 
recovery, a fresh cold may bring about a recurrence of the cough 
and whooping spells. The average duration of an ordinary 
case is about six weeks, but the course is influenced by treat- 
ment and by the child's recuperative powers and the occurrence 
of a complication. 

The attack begins as an ordinary cold, indistinguishable in 
the beginning from a simple upper respiratory infection, with, 
however, this difference, that instead of yielding to treatment 
in the course of a few days, or abating of its own accord, the 
cough gradually increases in frequency and severity, soon as- 
suming the paroxysmal and spasmodic type characteristic of 
the disease. An early symptom that should always arouse sus- 
picion is the nocturnal aggravation of the cough from the very 
beginning. Another diagnostic sign of value at this stage of 
the disease is the presence of a lymphocytosis. 

Examination of the chest at this time reveals nothing beyond 
a slight bronchitis. In the very beginning there is usually in- 
disposition, running of the nose, a short, dry cough, and slight 
fever. These symptoms soon abate, but the cough increases in 
severity. The cough is characterized by a sudden, loud expul- 
sive effort, followed in rapid succession by similar efforts of 
gradually decreasing force; through these continued explosions 
the chest is almost completely emptied of air, so that the child 
is obliged to draw in a deep breath at the end of the paroxysm. 
As the glottis is narrowed during this long-drawn inspiration, 
a loud, piping sound is produced, constituting the whoop, from 
which the disease is named. As soon as the lungs have been re- 



ACUTE INFECTIOUS DISEASES 537 

filled the cough begins anew, consisting, as before, of rapidly 
following expulsive efforts, ending with the whoop. This con- 
tinues (two to six coughing fits) until the paroxysm is ter- 
minated either by the dislodgement of a plug of mucus from the 
trachea, or by the vomiting of the ingesta or of a quantity of 
tenacious mucus. 

During such an attack the face becomes red, even livid; the 
eyes are injected and bulging, and the child clings to the nearest 
object for support, or stands with the feet wide apart and the 
hands resting upon the knees. Bleeding from the nose fre- 
quently occurs during the paroxysm, and cortical hemorrhages 
from the meningeal vessels may occur in severe cases. When 
such a hemorrhage is extensive, hemiplegia and convulsions 
will follow. This hemorrhagic tendency is one of the most 
serious aspects of whooping-cough. Sub-con junctival hem- 
orrhage is quite common, as are also minute hemorrhages about 
the eyes and face. No doubt the action of the pertussis toxin 
upon the blood-vessels is responsible for the condition. 

The number of paroxysms in a day will vary greatly in differ- 
ent cases. They are usually more frequent during the night. 
In very young children the cough is not as characteristic as in 
older ones, the whoop being especially faint or indistinct, but 
the same paroxysmal nature of the cough is present and cyanosis 
is more pronounced. 

The face gradually assumes a bloated appearance from the 
recurring vascular engorgement, and the eyes are deeply in- 
jected; slight hemorrhages may be seen under the conjunctiva. 
The eyes are unnaturally moist. Under the tongue a character- 
istic sign is frequently seen, namely, ulceration of the frenum. 
This is induced by the repeated propulsion of the tongue over 
the lower incisor teeth in coughing. In my experience it has 
only been present when there was at the same time catarrhal 
stomatitis in association with the whooping-cough, rendering 
the mucous membrane particularly vulnerable. 

With the decline of the disease the paroxysms become less 



538 DISEASES OF CHILDREN 

frequent and less severe, soon losing the spasmodic character 
of the cough, and the expectoration becomes muco-purulent, as 
in an ordinary bronchitis. With a fresh cold the whoop may re- 
appear ("after-pertussis"). This does not indicate a relapse 
in the sense of a reinfection but simply the persistence of the 
spasmodic habit which has been estabKshed and every cough 
will show evidence of this element for a long time after an 
attack of pertussis. With the advent of pneumonia, however, 
the cough losses its spasmodic character. 

The commonest complications of whooping-cough are 
bronchopneumonia (in the winter months) and entero-colitis 
(summer months). The advent of bronchopneumonia is recog- 
nized by the appearance of fever, together with rapid respira- 
tions and dyspnea, and suberepitant rales throughout the 
chest. The cough loses its paroxysmal character during the 
height of such a complication. 

Diarrhea is liable to become a troublesome symptom in deli- 
cate children, especially during the summer months. 

Convulsions are frequent among infants. They may be due 
to asphyxia, meningeal hemorrhage or pneumonia. Meningitis 
rarely, if ever, results from whooping-cough, although marked 
meningeal symptoms due to hyperemia of the brain and edema 
of the pia mater may be observed. 

Dilatation of the heart, due both to the strain on the heart 
as well as to the action of the toxin upon the myocardium, 
may be observed (Koplik). 

As a sequela, tuberculosis is most to be dreaded. Whooping- 
cough, as is well known, is one of the most potent predisposing 
causes of tubercle, ranking second to measles in this respect. 
This is due to the fact that in both of these diseases bronchitis 
and enlargement of the bronchial glands is a constant occur- 
rence. 

The prognosis depends to a great extent upon the age and 
previous health of the child. Normal children above five 
years of age seldom suffer great inconvenience or serious after- 



ACUTE INFECTIOUS DISEASES 539 

complaints under proper treatment. The prognosis becomes 
grave when bronchopneumonia is added, or where the hemor- 
rhagic tendency is marked. In the case of infants the prognosis 
is more grave. There is a greater tendency to pneumonia at 
this age and the infant is less able to withstand the exhausting 
coughing spells and the constant vomiting. 

Diagnosis. — During the prevalence of an epidemic the 
diagnosis should present no difficulties. Isolated cases, how- 
ever, may become puzzling, especially when atypical. The char- 
acter of the cough, together with the accompanying signs 
described under the symptomatology, should help out in 
differentiating whooping-cough from an ordinary bronchitis. 

Prof. Filatow, of Moscow, confirms the researches of Hip- 
pius and Blumenthal, who noticed that pertussis patients have a 
pale urine of high specific gravity. The occurrence of a lymph- 
ocytosis during the catarrhal stage is also suggestive of pertussis. 

Hyperplasia of the bronchial glands frequently provokes a 
paroxysmal cough, but the course is a chronic one, and there 
is associated bronchitis, and usually tuberculous foci else- 
where in the chest. Other possibilities of error are found in 
the so-called "spasmodic bronchitis" of infants, and catarrhal 
laryngitis (false croup). 

Treatment. — Isolation is difficult to carry out, as the disease 
is already contagious during the stage at which it cannot always 
be recognized. Nevertheless, every effort should be made to 
protect delicate children and infants against exposure by ex- 
cluding from their presence, during an epidemic, all children 
with colds or coughs. Prophylactic injections of pertussis vac- 
cine have been used extensively in recent years. Hess in 1914 
gave prophylactic vaccine to 244 children during an epidemic 
in an Infant Asylum and only 6 cases developed the disease. 
Shaw, of the New York State Board of Health, reports 164 
children exposed to pertussis who received vaccine and only 
11 cases contracted it. He advises the use of large doses, 
namely 500 million for the first injection, one billion for the 



540 DISEASES OF CHILDREN 

second and two billion for the third, giving the injections e very- 
second or third day. 

The patient should receive as much air as possible, and in 
pleasant weather may be permitted to be out-of-doors. Pro- 
tracted cases do well from a change of climate, the seashore 
being particularly beneficial. 

If the cough is very troublesome at night, and especially in 
the case of infants in whom asphyxia is to be feared, the vap- 
orizing of cresoline, creasote or oil of eucalyptus in the sick 
room is often attended with good results. Holt prefers creasote, 
vaporized in a croup-kettle. 

The remedies recommended for whooping-cough are legion, 
and space forbids enumeration of so long a list. While there 
are, perhaps, a dozen which are used a hundred times when the 
others are used but once, still it is impossible to tell just which 
remedy will be of the greatest benefit in a given case before the 
symptoms have been carefully considerd. The popular feeling 
as to the clinical value of our remedies in this affection is well 
presented by the following statistical report by Dr. Geo. B. Peck 
(Trans. American Institute of Homeopathy 1898) : "Out of 
every thousand prescriptions by members of this Society for 
the amelioration of that group of morbid phenomena popularly 
designated whooping-cough, at least 175 are for drosera, 153 
for belladonna, 123 for ipecacuanha, 76 for cuprum (metalli- 
cum and aceticum), 54 for corrallium rubrum, 4:4: for antvmon. 
et pot. tartaricum, 24 for mephitis/' etc. 

In the early stages aconite, bell., or ipecac may be indicated. 
When the characteristic spasmodic cough is established bella- 
donna is the chief remedy. This may be later alternated with 
ipecac as vomiting is a prominent symptom or tartar emetic 
when there is considerable bronchitis with rattling of mucus in 
the large tubes. 

The following remedies should be studied for special symp- 
toms and complications: 

Arnica. — Painful paroxysms (bryonia) ; tendency to hem- 
orrhages; meningeal hemorrhage. 



ACUTE INFECTIOUS DISEASES 541 

Bell. — Intense redness of face during paroxysm; mental ex- 
citement; child becomes very much frightened from the cough- 
ing paroxysms and awakens with suffocating spells at night. 
Convulsions. The most important remedy in the early stage. 

Carbo veg. — Protracted cases. Follows well after drosera. 
Hoarsness; anemia; sluggish circulation; flatulent indigestion. 

Coccus cacti. — Cough, especially worse in the early morning, 
followed by the expectoration of yellowish or bloody, tough mu- 
cus. This remedy has proven of value during the early par- 
oxysmal stage when abundant, stringy expectoration is present. 

Drosera. — Paroxysmal stage. Worse after midnight; gag- 
ging and vomiting predominate ; the expectoration is frequently 
blood-streaked; tuberculous diathesis. Personally, I have been 
disappointed in the results seen from this remedy but many 
homeopathic physicians consider it specific for pertussis. 

Hyos. — Incessant cough when lying down, relieved by 
sitting up. 

Ipecac. — Spasm of the glottis before paroxysm; the child 
stiffens out during the cough and becomes blue in the face. 
Bronchopneumonia, with abundant fine rales; vomiting after 
cough. The expectoration is often blood-streaked. Hughes re- 
commends beginning all cases with aconite and ipecac in al- 
ternation. 

Mephitis. — During the spell the child passes both urine and 
feces; diarrhea and flatus very offensive; the child must be 
taken up during the cough, turns blue in the face and seems 
asphyxiated. MepJiitis is rarely used excepting in severe types 
of the disease. 

Naphthalin. — Goodno recommends this remedy to be used 
as soon as the case is recognized. He employs the first deci- 
mal trituration. 

Tartar emetic. — Bronchopneumonia. Rattling of mucus in 
larger tubes; deficient oxygenation of blood. As a routine 
prescription, used in alternation with belladonna, this is one 
of the most useful remedies. 



542 DISEASES OE CHILDREN 

Vaccine therapy has been tried in the treatment of pertussis 
but its chief value lies in its prophylactic effect. Three injec- 
tions, of 500 million, should be given at three days intervals. 
After the disease has become fully established the results from 
the use of a vaccine are disappointing. 

PAROTITIS. 

Epidemic parotitis, or mumps, is an acute infectious disease 
in which the parotid glands become inflamed and markedly 
swollen. The specific contagion is not known, but it no doubt 
gains access into the gland through the duct of Steno, setting 
up an intense hyperemia, followed by a profuse serous exuda- 
tion (soft swelling). The process begins in the ducts and acini 
of the gland, rarely extending to the interstitial connective 
tissue, and never terminates in suppuration. For this reason 
resolution is perfect in the vast majority of cases, as the tume- 
faction is the result simply of hyperemia and edema and not 
of structural changes in the gland. 

Secondary parotitis is an infection of the parotid gland 
(usually one-sided), with pyogenic micro-organisms, occurring 
during the course of one of the infectious fevers. It may com- 
plicate typhoid fever, diphtheria, scarlet fever, small-pox and 
measles, rendering the prognosis grave. In these cases the 
submaxillary gland is rarely spared. It differs from mumps 
in terminating in suppuration, the entire parenchyma of the 
gland being more or less involved in the destructive process. 

Mumps appears epidemically, although never to the extent 
attained by epidemics of the other prominent contagious dis- 
eases of childhood. Close contact seems necessary for infec- 
tion. It is most prevalent during the damp seasons of the 
year. The period of incubation is from two to three weeks. 
One attack gives immunity against another. 

Symptoms. — For a day or two there may be a slight fever 
with lassitude, restless sleep, nervous irritability, loss of appe- 
tite, etc., preceding the appearance of the characteristic lesion. 



ACUTE INFECTIOUS DISEASES 543 

The inflammation of the gland induces first a painful stiffness 
of the jaw and tenderness in the region of the parotid. Swell- 
ing rapidly sets in, and in the course of a few days the gland 
will be swollen to its utmost extent. The fever may increase 
and the sleep become disturbed by restless dreams or delirium; 
convulsions have been known to occur in young children. The 
left parotid is the one most frequently attacked first. In the 
majority of cases the opposite side begins to swell in a day or 
two after the appearance of the first lesion. Sometimes the 
opposite parotid is not involved until the first begins to subside, 
or it may escape entirely. 

At the height of the disease-the face presents a ludicrous 
appearance. The entire parotid region stands out prominently 
from the presence of a tense, shining swelling which spreads 
anteriorly to the zygoma and posteriorly to the sternocleido- 
mastoid. The tumor feels firm over its centre while the edges 
pit on pressure. The enlargement is uniform and regular, not 
nodular as in lymphadenitis. It is also perfectly immovable, 
for the parotid gland is so firmly held down by the deep fascia 
as to render its displacement impossible. 

The fever now gradually subsides, usually not lasting more 
than from three to four days, but the patient is extremely 
uncomfortable, every effort at opening the mouth being at- 
tended with pain, and any article of food not bland in char- 
acter frequently exciting intense suffering. In fact, the pain 
produced by taking anything acid into the mouth is looked 
upon as pathognomonic and a symptom of diagnostic value. 
The swelling attains its height within three or four days, sub- 
siding by the end of a week. 

Metastases to the testicle in the male and to the ovary or 
breast in the female are not uncommon in older children at 
this time, i. e. during the stage of decline, but in young chil- 
dren this does not occur. Aside from the possibility of such 
a complication the prognosis is good. 

Secondary parotitis occurs during the course of one of the 



544 DISEASES OF CHILDREN 

acute infectious diseases, and begins as a hard, painful swell- 
ing, more circumscribed than in mumps, with an inflammatory 
blush soon showing itself over the surface. This gradually 
deepens in color; the swelling becomes more tense, and points 
of fluctuation can be elicited. The gland breaks down and pus 
can be expressed from its duct. The prognosis is always grave, 
although it is said to be less so when occurring late in the course 
of the disease which it complicates. 

Diagnosis. — It seems unnecessary to call attention to the 
question of diagnosis in a simple case of mumps, yet errors 
are sometimes made. One of the most frequent is the mis- 
taking of acutely enlarged cervical lymphatic glands for 
mumps; here the slower onset, the multilocular feel of the 
tumefaction and its movability will readily distinguish this 
condition from mumps. Furthermore in mumps the swelling 
begins in front of the lobe of the ear while in adenitis it is 
either below or posterior to the ear. Diphtheria with pro- 
nounced swelling of the cellular tissue of the neck, has likewise 
been mistaken for mumps, as has also mastoiditis. A sign to 
which attention has recently been called is redness and pointing 
of the orifice of Steno's duct on the affected side. 

Treatment. — The most important remedy is belladonna. 
It corresponds to the vascular engorgement, the fever, and the 
associated symptoms. 

Mercurius may be indicated early when there is but slight 
fever, pale swelling of the parotid region and gastric derange- 
ment. It is useful in the later stages of all cases to assist ab- 
sorption of the inflammatory products. 

For metastasis to the testicles Pulsatilla and clematis are the 
chief remedies. If induration with tendency to atrophy follows, 
aurum should be considered. 

Metastasis to the ovaries calls for apis, cimicifuga, pulsatilla, 
hamamelis. 

Secondary parotitis finds in rhus tox. its most useful remedy. 
As the process advances, hepar or arsenic usually becomes indi- 



ACUTE INFECTIOUS DISEASES 545 

cated. Calc. sulph. is the main remedy to promote healing 
after pus has been discharged either through fistulous openings 
or by means of an incision. As soon as the gland becomes 
swollen, hot fomentations wrung out of a 1 to 4,000 solution 
of the bichloride of mercury should be applied continuously. 

INFLUENZA. 

Influenza, or la grippe, is an acute infectious disease oc- 
curring pandemically and attacking all ages alike. It is char- 
acterized by fever of sudden onset and short duration, accom- 
panied by marked prostration and complicated with either 
catarrhal inflammation of the respiratory or alimentary tract, 
or by certain nervous phenomena. These characteristics dis- 
tinguish true influenza from the endemic cases of upper res- 
piratory infection commonly designated as grippe. 

The bacillus of Pfeiffer is the exciting cause, being found in 
almost pure culture in the sputum of influenza patients. It is 
a short, thin rod with rounded ends ; it does not stain by Gram's 
method and is best demonstrated with dilute fuchsin. It is 
difficult to cultivate; besides it usually disappears from the 
sputum early and for this reason its presence is often missed. 

The period of incubation is short, usually from one to three 
days. One attack does not afford immunity against another, as 
is the case in many of the epidemic infectious diseases ; on the 
contrary, it may even lead to an increased susceptibility to a 
fresh attack, or, reinfection may set in from a focus in the nose 
and throat, ears or bronchi. 

AYhile influenza, as a rule, pursues a short and acute course, 
nevertheless it shows a tendency to become protracted in many 
instances, sometimes becoming latent for a time and then sud- 
denly flaring up with acute manifestations. Again, bronchitis 
may persist for weeks, the secretion showing influenza bacilli 
in pure culture (Ortner, Modern Clinical Medicine, 1905) and 
a bronchopneumonia of a protracted course may likewise be due 
to the influenza bacillus, these cases presenting particular 
36 



546 DISEASES OF CHILDEEN" 

difficulty in their differentiation from pulmonary tuberculosis 
(Wassermann). 

Symptoms. — The disease begins abruptly with fever, severe 
headache, general aching and prostration. The fever remains 
at its height for a period of from three to five days, during the 
entire course of which prostration is marked, and headache and 
muscular aching are usually very distressing. A symptom 
present at this time and upon which Furbringer, of Berlin, lays 
great stress, is marked redness of the face. This shows itself 
as a diffuse flush and differs from scarlet fever in the absence 
of the white line about the mouth and pallor of the forehead. 
As Furbringer also points out, there is often present a slight 
icteric discoloration of the skin, although there is not much 
evidence of bile in the urine. During the epidemic of 1918 
many cases ran a characteristic temperature curve in which 
there was a high fever of abrupt onset for three days which fell 
to or near normal and then again rose with the appearance of 
chest symptoms (bronchitis or bronchopneumonia). The symp- 
toms noted were cough, increase in the fever, increased pulse 
and respiratory rate, and the development of dry and moist 
rales in the bronchi and subcrepitant rales at one or both bases 
of the lungs. In unfavorable cases cyanosis, increasing pros- 
tration and circulatory failure with a terminal pulmonary 
edema occurred. 

Several clinical types are to be encountered, depending upon 
the predominance of catarrhal or nervous symptoms and the 
locality chiefly attacked. Thus, there is the cerebral form 
characterized by a predominance of headache, together with 
delirium, and even unconsciousness, some of these cases sim- 
ulating meningitis; the abdominal form, characterized by 
vomiting, anorexia, gastralgia, diarrhea, some with predomin- 
ance of gastric symptoms, others simulating typhoid fever; the 
neuralgic form, in which there are neuralgic pains in the periph- 
eral nerves and other regions; the thoracic form compli- 
cated by bronchopneumonia, and the catarrhal form, the 



ACUTE INFECTIOUS DISEASES 547 

commonest variety, in which catarrh of the upper respiratory 
tract is the most prominent symptom. Extreme prostration, 
however, is common to all forms, this being the chief feature of 
the disease. The toxin exerts a most potent influence upon the 
nervous system, which manifests itself as prostration, cardiac 
weakness and neuralgic pains, and during convalescence in the 
persisting prostration and the strong tendency to the develop- 
ment of neurasthenia, perineuritis, insomnia, persistent head- 
ache, and even insanity. Fortunately these complications are 
not as common in children as in adults, and, taken altogether, 
the prognosis is better, although a complicating broncho- 
pneumonia is always of serious import. As in the case of 
measles and whooping-cough, a predisposition to infection with 
the tubercle bacillus is created. 

Nephritis may occur in influenza; sometimes this is of the 
hemorrhagic type. 

Rhinitis and acute otitis media are among the commonest 
complications. There is less tendency to mastoiditis than in 
scarlet fever but the otitis often runs a protracted course. 

Bronchopneumonia is the most serious complication and is 
the cause of the majority of fatalities. Empyema is usually 
due to secondary infection with the streptococcus and is more 
serious than the form following lobar pneumonia. 

The prognosis depends upon the age of the patient, the 
previous health and the presence of complications. Filatow lays 
stress upon the fact that in childhood it is mainly during the 
first to third year that the grave cases are encountered. 

The diagnosis seldom presents difficulties during the prev- 
alence of an epidemic, but isolated cases may be mistaken for 
a variety of other affections, particularly in the beginning. The 
catarrhal symptoms, hard cough and drowsiness may lead to a 
suspicion of beginning measles, but the subsequent course soon 
corrects this error. From pneumonia it is to be distinguished 
by the absence of physical signs limited to a pulmonary lobe; 
the presence of a leucopenia and the short course of the primary 



548 DISEASES OF CHILDREN 

fever. When pulmonary symptoms develop during the second- 
ary rise in the temperature they are in the nature of a compli- 
cation. Bacteriological examination of the sputum and nasal 
secretion may or may not give positive information. Cerebral 
cases may simulate meningitis or cerebrospinal meningitis. 
The mild cases of grippe (upper respiratory infection) above 
alluded to present none of the profound toxic manifestations of 
influenza. In protracted cases the condition is often very 
puzzling. Such cases may simulate tuberculosis. Here the 
absence of the characteristic apical signs of tuberculosis and 
the bacteriological examination of the mucous secretions are the 
most conclusive diagnostic data. 

Treatment. — The child should be kept in bed, absolute rest 
enforced, and strict isolation carried out. 

The diet should be highly nutritious, but to prevent gastro- 
intestinal complications, easily digested food only should be 
selected. When the pulse becomes weak and irregular a moder- 
ate amount of whisky should be administered at regular inter- 
vals. During convalescence a change of climate may be desirable 
and milk and eggs should be given in conjunction with the reg- 
ular diet. 

The most important remedies are aconite, gelsemium and 
bryonia in the beginning of the disease. Aconite is most useful 
in cases of sudden onset with high fever before any complica- 
tions have developed. Ferrum phos. is useful for the early 
stage of the bronchitis, the symptoms upon which it is chiefly 
prescribed being a hoarse cough with blood-streaked expector- 
ation. Belladonna is frequently indicated by the flushed face, 
somnolence and hard, barking cough. When the cough is deep 
and painful, bryonia is indicated, either alone or in alternation 
with aconite. For the pneumonic complications phosphorus, 
tartar emetic and scilla maritima are the most frequently useful 
remedies. 

Arsenicum is indicated where the prostration is extreme and 
presents the chief manifestation of the disease. There may also 



ACUTE INFECTIOUS DISEASES 549 

be sneezing; acrid, watery coryza; the process extending to the 
chest, with cough and dyspnea; great restlessness. 

Bryonia — Pains in the muscles, every limb aching intensely ; 
lies perfectly quiet and does not wish to be disturbed; dry, 
painful cough. Bronchopneumonia complicating influenza 
{ant tart., phosphorus). 

Eupatorium perf. — Deep-seated aching in the back and ex- 
tremities, as if the bones would break; the skin is slightly 
jaundiced and the tongue heavily coated; bilious vomiting. 

Gelsemium. — The symptomatology of gelsemium presents a 
true picture of the average case of grippe. The condition begins 
with lassitude and chilliness; "creeps" especially up and down 
the back, and the patient hugs the stove to get warm. He feels 
prostrated, every part of the body aches, and he complains of 
headache, soreness and sensitiveness of the eyes, obstruction of 
the nose, sore throat and prostration. The soft, weak pulse, 
heavy eyelids and flushed appearance of the face are very char- 
acteristic of gelsemium. 

Pulsatilla. — Catarrhal symptoms predominate; mild, tearful 
disposition, the tongue is heavily coated and covered with 
viscid saliva, but there is no thirst; the patient is constantly 
chilly; otitis media. 

MALARIA; MALARIAL FEVER. 

Malaria represents a group of febrile affections resulting 
from infection with micro-organisms belonging to the class of 
protozoa. Each type of malarial fever is traceable to a distinct 
variety of micro-organism, possessing its own morphological 
and biological peculiarities. There is a specific parasite for 
tertian intermittent fever, for quartan intermittent fever, and 
for estivo-autumnal fever, or tropical malaria. These para- 
sites attack the red blood-corpuscles, in which they live and de- 
velop to full maturity and sporulation. With the completion 
of sporulation a malarial paroxysm occurs. The tertian organ- 
ism requires forty-eight hours to undergo a complete develop- 



550 DISEASES OF CHILDREN 

mental cycle ; consequently a patient infected with this parasite 
will experience a paroxysm every third day, i.e., with the occur- 
rence of sporulation. Infection with the quartan parasite 
results in a paroxysm occurring every fourth day. Double in- 
fection with the tertian parasite, each group maturing on sep- 
arate days, results in daily paroxysms. This is the most 
frequent type in the acute intermittent fevers in this latitude 
(Osier). Quartan fever is extremely rare in this country. 
This parasite may be present in the blood coincidently with the 
tertian parasite. By such a combination most puzzling types 
of fever are produced. The parasite of estivo-autumnal fever 
is smaller than the other types of parasites, and is practically 
confined to the Southern States in this country. 

The disease prevails endemically in certain localities, which 
are known as malarial regions. Although low, swampy and 
poorly drained regions and the banks of sluggish streams are 
the most frequent localities for malaria, still it also exists in 
many of the larger cities, especially in their suburbs and along 
the river fronts. The disease is conveyed to man by the sting 
of the mosquito, the genus anopheles being the one capable of 
acting as a host for this parasite. Malaria has no doubt in- 
creased in the northern cities since the influx of laborers from 
the South and from Italy has grown to such proportions. 

The pathological changes resulting from malarial infection 
are extreme anemia, due to destruction of the red corpuscles 
by the parasite; enlargement of the spleen, which may lead to 
hyperplasia of the same ; pigmentation in the liver, kidneys and 
brain. In cases which have resulted fatally there may be in- 
tense pulmonary congestion or pneumonia; nephritis; gastro- 
enteritis. Fortunately, fatal cases are rare, the pernicious 
form of malarial fever being quite uncommon in this locality. 

Symptoms. — A typical malarial paroxysm, consisting of 
three well defined stages, namely, chill, fever, and sweat, is 
seldom seen in young children. Both the first and third stages 
may be absent or poorly defined. Instead of a chill there may 



ACUTE INFECTIOUS DISEASES 551 

be only the signs of a vasomotor spasm, such as blueness of the 
finger-nails, cyanosis of the face, cold extremities and yawning, 
or there may be vomiting, diarrhea and even convulsions or a 
comatose state preceding the accession of fever. In the course 
of an hour or less the fever rises rapidly and may reach an 
alarming height. This condition of hyperpyrexia lasts for an 
hour or two, ending by a gradual fall. Sweat may be entirely 
absent. 

When there is a complete remission of fever the child may 
appear well until the second paroxysm occurs. As the attacks 
recur they become more and more atypical, and a remitting 
fever may develop. 

Enlargement of the spleen and anemia develop, especially if 
the disease has lasted for some time. The symptoms accom- 
panying the febrile stage are those common to febrile disturb- 
ances in general. 

The prognosis is usually good. Untreated cases may take 
one of the following courses: (1) mild cases may go on to. 
spontaneous recovery; (2) the paroxysm may gradually dimin- 
ish in intensity, but grave anemia and chronic cachexia develop, 
or (3) the paroxysm may increase in severity and assume 
finally a pernicious type (Thayer, Lectures on Malarial Fever, 
1897). 

Mashed or Irregular forms of Malaria and Malarial Cach- 
exia. A malarial paroxysm may be so atypical, or affect a 
certain region to such a degree, as to entirely mask the condi- 
tion, the malarial element only being eventually suspected by 
the regularity of recurrence of the attack, the association of 
enlarged spleen and anemia, and possibly by a history of ex- 
posure to malarial infection or residence in a malarial district. 

Disturbances in the nervous system are common. Headache, 
continuous or recurring; neuralgia in various localities; inter- 
mittent spasmodic torticollis, accompanied by a slight rise 
in temperature and enlarged spleen (Holt) ; multiple neuritis. 
Trigeminal neuralgia is rare in children. Congestion of the 
lungs, simulating pneumonia, may occur paroxysmally. 



552 DISEASES OF CHILDREN 

Malarial cachexia may develop likewise without malaria 
having been suspected, either from the attacks being unaccom- 
panied by very high fever, or from presenting themselves in a 
masked form. The child is anemic and emaciated, the skin 
being dry and sallow. The face has a drawn, pinched look, and 
the eyes are surrounded by dark circles. Indigestion and di- 
arrhea, irregular febrile movements and enlargement of the 
spleen are usually present. 

Diagnosis. — Malarial infection should always be suspected 
when a periodic disturbance, accompanied by anemia and en- 
largement of the spleen, is encountered. In order to remove all 
question of doubt, a blood examination should be made. A 
negative result does not necessarily exclude malaria, as it may 
require several examinations in order to find the plasmodium. 
Even in the absence of the plasmodium a leucopenia together 
with an increase in the large mononuclear leucocytes is sugges- 
tive of malarial infection. 

Anemia infantum pseudo-leuhemica presents some of the 
symptoms of malarial cachexia, but the absence of fever, the 
leucocytosis and absence of the malarial parasite readily differ- 
entiate the two conditions. 

The remittent form of malarial fever is frequently con- 
founded with such conditions as the hectic fever of tuberculosis, 
typhoid fever, and the septic fever of empyema, pyelitis, etc. 
A careful process of exclusion is therefore necessary in order to 
justify a diagnosis of malaria. Finally, the therapeutic test is 
of value and may be tried in doubtful cases. 

Treatment. — Little can be done for the patient during a 
paroxysm. During the interval and during convalescence a 
tonic treatment is indicated. Cases simulating typhoid fever 
are to be managed on the same general principles applying to 
such cases. 

Remedies prescribed in malarial fevers are usually divided 
into three classes: (a) those possessing a specific and abortive 
influence over the paroxysms, (b) those indicated for general 



ACUTE INFECTIOUS DISEASES 553 

disturbances arising during and complicating the paroxysm, 
(c) those indicated in the chronic form and for the cachectic 
manifestations. 

To the first class cinchona and its alkaloid, quinine, belong 
pre-eminently. We must all admit its definite action in typical 
cases of malarial fever and accept it as the specific remedy for 
the disease. 

The true sphere of cinchona lies in that class of cases which 
presents each stage well marked, with the absence of any com- 
plications or symptoms not directly traceable to the febrile 
paroxysm. Chininum sulph. is supposed to exhibit greater 
regularity in the time of occurrence of the paroxysm, besides 
possessing some symptoms not found under cinchona. For a 
fuller description of these remedies and their special indications 
in intermittent fever I must refer to Allen's Therapeutics of 
Intermittent Fever. As to the dose, that is unfortunately a 
matter of contention. ■ Kafka (Homeopatishe Therapie) sums 
up his experience as follows : "Given on exact indications, 
quinine acts in small as well as in larger doses, but not in 
infinitesimal doses. While the most beautiful results were 
attained with the lx trituration, or even stronger doses of one 
to two grains given every two hours during the period of apy- 
rexia, we exerted ourselves in vain with the 2d , 3d, etc." 
Goodno {Practice of Medicine) expresses similar views and he 
recommends the usual therapeutic dose. Personally, I believe 
that it is necessary to give a sufficient amount of quinine to 
destroy the plasmodium in order to cure the case. 

In malarial cachexia arsenicum is the most important 
remedy. 



INDEX 



Abscess, peritonsillar, 403 

retropharyngeal, 407 
symptoms, 408 
treatment, 408 
Acidosis, 115, 138 
Adenitis, tuberculous, 456 

treatment, 457 
Adenoid vegetations, 418 

diagnosis, 420 

pathology, 418 

symptoms, 419 

treatment, 421 
Airing of nursery, 3 
Albuminuria, cyclic, 243 

lordotic, 243 

orthostatic, 243 

postural, 243 
Amentia, 307 
Amyotonia congenita (v. mya- 

tonia), 387 
Anemia, aplastic, 290 

infantum pseudo-leukemia von 
Jaksch, 291 

pernicious, 293 
etiology, 293 
symptoms, 294 
treatment, 294 
Anemia, primary, 290 

secondary, 290 

splenic, 297 

with leucocytosis, 291 
Anemia, treatment of, 294 
Angina, Vincent's, 403 
Anomalies of heart (v. heart anom- 
alies), 222 
Antitoxin, diphtheria, 502 

dosage, 502 

technique of injection, 502 
Aphthae, Bednar's, 98 

epizooticae, 98 



Apthous stomatitis (v. stomati- 
tis), 96 
Appendicitis, 154 

diagnosis, 155 

symptoms, 155 

treatment, 156 

varieties, 154 
Artificial foods, 78 
Ascaris lumbricoides, 159 
Asphyxia, extra-uterine, 83 

intra-uterine, 83 

neonatorum, 83 

sudden death from, 92 

treatment, 84 
Astasia abasia, 367 
Asthma, bronchial, 174 

of Millar, 174 

thymic, 174 

diagnosis, 176 

symptoms, 175 

treatment, 176 

Ataxia, family, 383 

hereditary cerebellar, 383 
Ataxia course 384 

diagnosis, 384 

symptoms, 383 
Atelectasis in newborn, 93 
Athrepsia (v. marasmus), 422 
Aura, epileptic, 345 
Auscultation, general methods, 20 

Babinski's sign, 15, 305 

Barlow's disease (scurvy), 438 

Bathing, 1 

Baths, 6 

Bednar's aphthae, 98 

Birth Palsies, 371 

Blood corpuscles, morphology, 285 

differential count, 289 

disease of, 285 



556 



INDEX 



Blood corpuscles, erythrocytes, 285 

determination of, 288 

in anemia, 290 

in chlorosis, 292 

in leukemia, 297 

in pernicious anemia, 290 

leucocytes, 285 

determination of, 289 

specific gravity, 290 
Boils (v. furunculosis), 274 
Bowels, training of, 3 
Brights' disease (v. nephritis, 

chronic), 257 
Bronchitis, acute, 168 

diagnosis, 170 

pathology, 169 

symptoms, 169 

treatment, 170 
Bronchitis, capillary, 177 

chronic, 172 
pathology, 172 
symptoms, 172 
treatment, 172 
Bronchopneumonia, acute, 177 

diagnosis, 182 

etiology, 177 

pathology, 178 

prognosis, 181 

symptoms, 180 

treatment, 183 
Buhl's disease, 89 

Caloric requirements in infancy, 59 
Carpo-pedal spasm, (v. tetany), 

443 
Case, method of taking, 11 
Cephalhematoma, 84 
Cerebral palsy, (v. palsy), 371 
Cerebro-spinal fever, epidemic, 315 

meningitis, epidemic, 315 
Chicken-pox (v. varicella), 532 
Chlorosis, 291 

blood in, 292 

etiology, 291 

prognosis, 293 



Chlorosis, symptoms, 292 

treatment, 294 
Cholera infantum, 132, 134, 137 

treatment, 143 
Chorea, 353 

diagnosis, 359 

etiology, 353 

pathology, 354 

symptoms, 355 

treatment, 359 

in rheumatism, 467 
Chvostek's symptom, 444 
Clinical examination, methods, 10 
Clothing, 5 
Cceliac disease, 112 
Colles' law, 459 
Colostrum, 44 
Constipation, 150 

symptoms, 151 

treatment, 152 
Constitutional diseases, 422 

remedies, 32 
Consumption (v. tuberculosis), 450 
Convulsions (v. eclampsia), 339 

epileptic (v. epilepsy), 343 
Convulsive affections, 339 
Cowpox (v. vaccinia), 528 
Cow's milk (v. milk), 61 
Craniotabes (v. rickets), 430 
Cretinism, 312 

sporadic, 312 
Croup, membranous, 490 

spasmodic (v. laryngitis, acute 
catarrhal), 166 
Croupous pneumonia (v. pneumo- 

ria), 186 
Cry, character of, 16 
Curds, chemical examination of, 40 
Cyclic albuminuria (v. albuminu- 
ria), 243 

vomiting, 119 

Dactilitis, 461 
Deaf -mutism, 310 
Deformities of heart, 222 



INDEX 



557 



Dentition, 94 

delayed, 94 
D'Espines' sign, 454 
Diabetes, 254 
insipidus, 254 
diagnosis, 254 
etiology, 254 
pathology, 254 
symptoms, 254 
treatment, 254 
mellitus, 255 
diagnosis, 256 
diet, 257 
pathology, 256 
symptoms, 256 
treatment, 257 
Diarrhea 128 
dyspeptic, 129 
acute infectious, 132 
etiology, 132 
diagnosis, 138 
pathology, 135 
prognosis, 137 
symptoms, 136 
treatment, 143 
fermental, 129 

simple (v. indigestion, acute 
intestinal), 129 
Digestive tract, anatomy of, 34 

physiology, 34 
Diphtheria, 489 
antitoxin, 502 
diagnosis, 499 
etiology, 490 
intubation in, 501 
laryngeal or membranous croup, 
496 

statistics, 501 
treatment, 501 
nasal, 496 

treatment, 501 

paralysis after, 495 

pathology, 492 

prognosis, 498 

pseudo, 497 



Diphtheria, pseudo, clinical course, 
497 

scarlatinal, 482 

septic, 496 
symptoms, 493 
treatment, 499 
Diplegia, 372 
Diseases, acute infectious, 471 

blood, 285 

ear, 393 

heart, 219 

intestines, 104 

kidneys, 242 

mouth, 94 

nervous system, 304 

new-born, 83 

nose, 393 

peritoneum, 161 

respiratory tract, 165 

skin, 268 

stomach, 104 

throat, 393 

urinary organs, 242 
Dosage of remedies, 25 
Dysentery, 138 

diagnosis, 143 

etiology, 138 

pathology, 139 

symptoms, 141 

treatment, 144 
Dyspepsia, 106 

chronic (v. indigestion chro- 
nic), 109 
Dystrophy, idiopathic muscular, 382 

facio-scapulo -humeral, 382 

infantile, 382 

juvenile, 382 

peroneal, 382 
Ear diseases, 393 
Earache, 394 
Eclampsia, 339 

diagnosis, 341 

prognosis, 340 
symptoms, 339 
treatment, 343 



55! 



INDEX 



Eczema, 270 

diagnosis of, 271 

etiology of, 270 

symptoms, 270 

treatment, 272 

varieties of, 270 
Edema, 245 
Emphysema, 209 
Empyema (v. pleurisy), 210 
Encephalitis, lethargic, 332 

diagnosis, 334 

symptoms, 332 

treatment, 334 
Endocarditis, 230 

bacterial, 232 

fetal, 222 

diagnosis, 235 
prognosis, 233 
symptoms, 231 
treatment, 237 
Enemata, 8 
Enteroclysis, 8 
Enuresis, 262 

diagnosis, 264 

symptoms, 263 

treatment, 264 
Epilepsy, 343 

diagnosis, 346 

etiology, 343 

hystero, 366 

prognosis, 346 

symptoms, 344 

treatment, 347 
Erysipelas, new-born, 86 
Erythema, 270 

intertrigo, 268 

scarlatinoides, 273 
Exanthemata, 471 
Exudative diathesis, 442 
Exercise, 4 

Feces (v. stools), 37, 38 
Family ataxia (v. ataxia), 383 
Feeding, infant, 34 

mixed, indications for, 45 



Fetal endocarditis, 230 
Fever, 315 

glandular (v. glandular fever), 
503 

malarial (v. malaria), 549 

typhoid (v. typhoid fever), 505 
Food, calorie values of, 50 

diet, 1 yr. to 18 months, 75 
18 months to 2 yrs., 75 
over 2 years, 73 

during the second year, 73 

artificial, 56 

forbidden, 76 

ingredients, method of calculat- 
ing, 67 

preparation of, 71 

quantity required, 63 
Foods, albumin milk, special, 78 

albumin water, 77 

barley-water, 77 

beef -juice, Benger's, 81 

Brook's Baby Barley, 79 

condensed milk, 80 
unsweetened, 81 

Czerny-Kleinschmidt butter- 
flour, 427 

Dextri-Maltose, Mead's 79 

Dryco, Dry Milk Preparations, 
81 

Eskay's, 80 

Horlick's Malted Milk, 80 

Kellers Malt Soup, 78 

malt soup extracts, 82 

mammala, 81 

Mellin's, 80 

Nestle 's, 80 

Peptogenic Powder, 81 

proprietary, 78 

Eobinson 's Patent Barley 
Flour, 79 

vegetable soup, 78 

whey, 78 
Formulas for modifying cow's 

milk, 64 
Friedreich 'g disease (v. ataxia) , 383 



INDEX 



559 



Functional heart disease (v. heart 

diseases), 219 
Furunculosis, 274 

symptoms, 274 

treatment, 275 

Gastrointestinal tract, diseases of, 

104 
German measles (v. measles), 488 
Glandular fever, 503 

diagnosis, 504 

etiology, 503 

symptoms, 504 

treatment, 505 
Glottis, spasm of, 165, 445 
Glycosuria, 138, 255 
Gonorrhea (v. vulvo- vaginitis), 265 
Gonorrhea, newborn, 87 
Grand mal (v. epilepsy), 343 
Grippe (v. influenza), 545 
Growing pains, 467 

Headache, 390 

diagnosis, 391 

etiology, 390 

symptoms, 390 

treatment, 391 
Head-nodding (v. spasmus nut- 
ans), 362 
Heart anomalies, congenital, 222 
Heart, defect of septum, 222 

congenital diseases, 222 

deformities, 222 

diseases, 219 

disease, chronic valvular, 230 

murmurs, 221 

patent ductus arteriosus, 223 

patent foramen ovale, 223 

sounds, 221 

stenosis of pulmonary artery, 
223 
treatment, 224 
symptoms, 224 

valvular defects, 230 
Heat, therapeutic use of, 6 



Hematoma of sterno-mastoid mus- 
cle, 85 
Hematuria, 246 

in scurvy, 441 
Hemoglobin, determination, 288 
Hemoglobinuria, 246 
Hemophilia, 300 

pathology, 300 

prognosis, 301 

treatment, 301 
Hemorrhagic diathesis, 300 
Hemorrhage, gastro-intestinal, 91 

newborn, 91 
Hemiplegia, 372 
Henoch's purpura, 456 
Hereditary syphilis, 456 
Hirschsprung's disease, 113 
Hives (v. urticaria), 277 
Hodgkin's disease (v. leukemia), 

297, 298 
Human milk (v. milk), 62 
Hutchinson's teeth, 96 
Hydrocephalus, 335 

acute (v. meningitis, tubercu- 
lous), 323 

chronic, 335 
diagnosis, 338 
symptoms, 336 
treatment, 338 
Hygiene, 1 
Hypertrophic pyloric stenosis, 125 

diagnosis, 127 

prognosis, 126 

symptoms, 125 

treatment, 127 
Hysteria, 363, 364 

accidents, 366 

diagnosis, 369 

prognosis, 369 

stigmata 365 

symptoms ,364 

treatment, 370 
Hystero-epilepsy, 366 

Icterus, neonatorum, 90 



560 



INDEX 



Idiocy, 307 

amaurotic family, 308 

by deprivation, 310 

cretinoid, 312 

epileptic, 309 

genetous, 308 

hydrocephalic, 308 

inflammatory, 309 

microcephalic, 308 

Mongolian, 311 

paralytic, 309 

sclerotic, 309 

syphilitic, 309 

traumatic, 310 
treatment, 310 
Ileo-colitis, acute (v. dysentery), 

138 
Imbecility, 307 
Impetigo contagiosa, 275 

diagnosis, 276 

etiology, 275 

symptoms, 275 

treatment, 275 
Inanition fever, 86 
Indigestion, acute intestinal, 129 
Indigestion, acute, 106 
etiology, 106 
symptoms, 107 
treatment, 107 

chronic, 109 
symptoms, 111 
treatment, 113 

gastric, 106 
Infantile convulsions (v. eclamp- 
sia), 339 

paralysis (v. poliomyelitis), 374 
Infantilism, 112 
Infant feeding (v. feeding), 34 

metabolism in, 48 
Infants, delicate, care of, 4 

premature, care of, 4 
Infectious diseases, acute, 471 
Influenza, 545 

abdominal, 546 

catarrhal, 546 



Influenza, 546 
cerebral, 546 
diagnosis, 547 
etiology, 545 
neuralgic, 546 
prognosis, 547 
symptoms, 546 
thoracic, 546 
treatment, 548 
Inhalations, 6 

Inspection, general methods, 13 
Interstitial nephritis (v. nephri- 
tis), 246 
Intestinal indigestion, acute, 129 
chronic, 109 
obstruction, 153 
parasites, 157 
symptoms, 157 
treatment, 160 
Intestines, 36 
Intubation, 501 
Intussusception, 153 
Irrigation of colon, 8 
Itch (v. scabies), 283 

Kernig's sign, 16, 305 

Kidneys, acute degeneration, 246 

diseases of, 242 

tumors of, 242 
Klebs-Loeffler bacillus, 491 
Knee-jerk, 16 

Koplik's sign (v. measles), 471 
Kyphosis, 14 

La grippe (v. influenza), 545 
Laryngismus stridulus, 165, 445 
Laryngitis, acute catarrhal, 166 

diagnosis, 166 

etiology, 166 

symptoms, 166 

treatment, 166 
Lavage, 7 

method of performing, 7 
Lethargic encephalitis, 332 
Leucocytes, 285 



INDEX 



561 



Leukemia, 297 
pseudo, 297 
symptoms, 297 
treatment, 299 
Lice (v. pediculosis), 282 
Lime water and other alkalies, 69 
Little's disease, 373 
Lumbar puncture, 327 
diagnostic value, 330 
indications for, 332 
operative technique, 328 
Lymphatic leukemia, 297 
Lymphatism (v. status lymphati- 
cus), 92, 447 

Macewen's sign, 18 
Malaria, 549 

blood in, 549 

diagnosis, 552 

irregular, 551 

masked, 551 

pathology, 550 

prognosis, 551 

symptoms, 550 

treatment, 552 
Malarial cachexia, 552 
Malnutrition, 422 
Marasmus, 422 

diagnosis, 425 

etiology, 423 

prognosis, 425 

symptoms, 424 

treatment, 426 
Mastitis in newborn, 89 
Maternal nursing, 43 
Measles, 471 

blood in, 475 

diagnosis, 

etiology, 471 

prognosis, 

treatment, 475 

symptoms, 472 
Measles, hemorrhagic, 473 

scarlatiniforme, 489 
treatment, 475 
37 



Measles, 488 

German measles, 488 
morbilliforme, 488 
symptoms, 488 
treatment, 475 
Meconium, 37 
Melena neonatorum, 91 
Membranous croup, 496 
Meningismus, 313 
Meningitis, 313 

basilar (v. meningitis,, tuber 

culous), 323 
cerebro -spinal, epidemic, 315 
abortive, 316 
diagnosis, 320 
etiology, 315 
pathology, 315 
prognosis, 319 
protracted, 316 
sequelae, 319 
symptoms, 316 
treatment, 321 
varieties, 316 
posterior basic, 317 
serous, 313 
tuberculous, 323 
diagnosis, 327 
pathology, 324 
prognosis, 327 
symptoms, 325 
Mental deficiency, 307 
Metabolism, carbohydrate, 53 
fat, 52 

infancy in, 48 
mineral salts in, 55 
protein, 51 
Methods of clinical examination, 
10 
of prescribing, 27 
Migraine, 390 
Miliaria, 269 

treatment, 269 
Milk, carbohydrate of, 62 
digestibility of, 61 
deficient in solids, 45 



562 



INDEX 



Milk, fat of, 62 

pasteurization of, 70 
proteins of, 61 
Milk dilutions, top, 65 
Milk formulae, 68 

method of estimating the num- 
ber of calories in, 69 
method of estimating the per- 
centages in, 68 
Mongolian idiocy, 311 

treatment, 312 
Monoplegia, 372 
Morbidity, infant, 10 
Morbilli (v. measles), 488 
Morbus maculosus Werlhofii, 303 
Moron, 307 
Mortality, infant, 10 
Mouth, care of, 2 
diseases of, 94 
putrid sore, 99 
Mucous colitis, 112 
Multiple neuritis (v. neuritis), 388 
Multiple sclerosis, 385 
Mumps, 542 

diagnosis, 544 
epidemic, 542 

prognosis, 543-544 
secondary, 542 
symptoms, 542 
treatment, 544 
Murphy drip, the, 9 
Muscular dystrophy (v. dystro- 

phy), 382 
Myocarditis, 239 
diagnosis, 240 
prognosis, 240 
symptoms, 240 
treatment, 241 
Myatonia congenita, 387 



Nephritis, acute, 246 
etiology, 247 
pathology, 247 
prognosis, 248 



Nephritis, acute, 247 
symptoms, 247 
treatment, 249 
chronic, 251 
interstitial, 252 
pathology, 252 
treatment, 253 
parenchymatous, 251 
pathology, 251 
Nephritis, chronic, 251 
symptoms, 251 
treatment, 253 
Nervous system, diseases of, 304 
Neuritis, multiple, 388 
diagnosis, 389 
symptoms, 388 
treatment, 389 
Neuropathic constitution, 363 
Newborn, apoplexy in, 85 
asphyxia, 83 
atelectasis, 93 
Buhl's disease, 89 
care of, 1 
diseases of, 83 
erysipelas, 86 

fatty degeneration, acute, 89 
gonorrhea, 87 
hemoglobinuria, 89 
hemorrhagic disease of, 91 
icterus, 90 

intestinal toxemia, 86 
intracranial hemorrhage, 85 
mastitis, 89 
ophthalmia, 87 
septic infection, 85 
sudden death, 92 
tetanus, 87 

vaginal hemorrhage, 90 
Night terrors, 306 
Noma (v. stomatitis), 101 
Nose, disease of, 393 
Nurse, wet, 47 
Nursing, 1 

maternal, 43 
Nursing, of sick children, 5 



INDEX 



563 



Obstruction, intestinal, acute (v. 

intussusception), 153 
Ophthalmia neonatorum, 87 
prognosis, 88 
treatment, 88 
Oppenheim's disease, 387 
Orange juice (v. scurvy), 441 
Orthostatic albuminuria, 243 
Otitis, 393 

influenzal, 395 
in scarlatina, 482 
media, acute catarrhal, 395 
diagnosis, 398 
prognosis, 397 
purulent, 395 
symptoms, 396 
treatment, 398 
tuberculous, 395 
Oxyuris vermicularis, 158 
Ozena, 413 

Pack, cold, 6 

hot, 6 

mustard, 6 
Palpation, general methods, 17 
Palsy, cerebral, 371 

symptoms, 372 
Paracentesis (ear), 399 
Paralysis, post-diphtheritic, 495 

pseudo-hypertrophic, 383 
Paralysis, spinal (v.poliomyeletis), 

377 
Paralytic affections, 371 
Paraplegia, 372 
Parasites, intestinal, 159 
Parasitic diseases, animal, 282 

vegetable, 278 
Parenchymatous nephritis (v. ne- 
phritis), 251 
Parotitis (v. mumps), 542 
Pasteurization, 70 
Pectus carinatum, 15 
Pediculosis capitis, 282 

diagnosis, 282 

symptoms, 282 



Pediculosis capitis, treatment, 282 
Peliosis rheumatica (v. purpura), 

302 
Pemphigus, 276 
Percussion, 18 
Pericarditis, 226 

pathology, 226 

prognosis, 229 

symptoms, 227 

treatment, 229 
Periodic vomiting, 119 
Peritoneum, diseases of, 161 
Peritonitis, acute, 161 
symptoms, 161 
treatment, 161 

chronic, 162 

tuberculous, 162 

diagnosis, 163 

symptoms, 162 

treatment, 164 

Peritonsillar abscess, 403 

Pertussis, 534 

complications, 538 

diagnosis, 539 

etiology, 535 

prognosis, 538 

sequelae, 538 

symptoms, 535 

treatment, 539 
Petit mal, 343, 344 
Physical examination, 13 
Pial hemorrhage, 85 
Piotrowski's reaction, 41 
Pirquet reaction, 452 
Pityriasis, linguae, 97 
Pleurisy, 210 

diagnosis, 214 

pathology, 211 

prognosis, 216 

symptoms, 212 

treatment, 216 
Pleuro -pneumonia (v. pneumonia), 

192 
Plica polonica (v. pediculosis), 282 
Pneumonia, abortive, 192 



564 



INDEX 



Pneumonia, broncho, 177 
catarrhal, 177 
central, 191 
cerebral, 190 
croupous (v. lobar), 186 
influenzal, 192 
lobar, 186 
complications, 193 
diagnosis, 195 
etiology, 186 
pathology, 187 
physical signs, 198 
prognosis, 195 
lobular (v. bronchopneumonia), 

177 
typhoid, 192 
wandering, 191 
Polioencephalitis, acute (v. polio- 
myelitis), 374 
Poliomyelitis, 374 
acute, 374 

diagnosis, 380 
etiology, 374 
pathology, 375 
symptoms, 376 
treatment, 380 
abortive, 376 
bulbospinal, 379 
cerebral, 379 
spinal, 377 
Polyserositis, 226 
Prescribing, method of, 27 
Prickly heat, 269 

Progressive muscular atrophy, 382 
Pseudo-diphtheria, 497 
Pseudo-hypertrophic paralysis, 383 
Pseudo -leukemia of von Jaksch, 

291, 297, 298 
Pseudo-meningitis (v. meningis- 

mus), 313 
Psychoses, 306 

Pulmonary tuberculosis (v. tuber- 
culosis), 197 
Pulse, 21 

in childhood, 220 



Purpura, 301 

fulminans, 303 

hemorrhagica, 303 

Henoch's, 302 

rheumatica, 302 

simplex, 302 
treatment, 303 
Pyelitis, 259 

symptoms, 260 

treatment, 261 
Pyloric stenosis (v. hypertrophic, 
pyloric stenosis), 125 

Quinsy (v. tonsillitis, parenchyma- 
tous), 403 

Rachitic rosary, 432 
Reaction of degeneration, 306 
Record keeping, 11 
Reflexes, the, 15 
Regurgitation, aortic, 232 

mitral, 231 
Respiration in childhood, 22 
Respiratory tract, diseases of, 165 
Retropharyngeal abscess, 407 
Rheumatic nodules, 467 
Rheumatism, 466 
diagnosis, 468 
treatment, 469 
Rhinitis, acute, 409 
symptoms, 409 
treatment, 410 
atrophic, 413 
etiology, 413 
prognosis, 416 
symptoms, 415 
treatment, 416 
chronic, 412 
symptoms, 412 
treatment, 412 
hypertrophic, 413 
etiology, 413 
symptoms, 414 
treatment, 415 
pseudo-membranous, 409, 410 



INDEX 



565 



Rhinitis, purulent (v. chronic), 412 
Rickets, 430 

etiology, 430 

pathology, 431 

prognosis, 436 

symptoms, 433 

treatment, 437 
Ringworm (v. tinea circinata), 

279, 281 
Rotheln (v. German measles), 488 
Rubella, (v. German measles), 488 
Rubeola, (v. measles), 471 

Sabre-blade deformity, 462 
Saint Vitus' dance (v. chorea), 353 
Scabies, 283 

diagnosis, 283 

pathology, 283 

treatment, 284 
Scarlatina (v.scarlet fever), 478 
Scarlet fever, 478 

complications, 482 

desquamation, 483 

diagnosis, 483 

diet, 486 

etiology, 478 

prognosis, 483 

symptoms, 480 

temperature in, 481 

treatment, 485 
Schick test, 490 
Sclerosis, 385 

multiple, 385 

diagnosis, 386 

symptoms, 386 

treatment, 386 
Scorbutus (v. scurvy), 438 
Scrofula, 452, 456 
Scurvy, 438 

infantile, 438 
diagnosis, 441 
etiology, 438 
symptoms, 439 
treatment, 441 
Seat-worms, 158 



Secondary anemia, 290 
Septic infection in new-born, 85 
Serum therapy (v. diphtheria), 501 
Simple anemia, 290 
Skin, diseases of, 268 
Sleep, 2 

Sleep, disorders of, 307 
Sleeping sickness (v. lethargic en- 
cephalitis), 332 
Small-pox (v. variola), 525 
Snuffles, 463 
Sore mouth, putrid, 99 
Spasm of the glottis, 165, 445 
Spasmus nutans, 362 
Spasmophilia, 443 
treatment, 447 
Splenic anemia (v. leukemia), 297 
Spleno-medullary leukemia, 298 
Spotted fever (v. cerebrospinal 

meningitis), 315 
Status lymphaticus, 92, 447 
Stenosis, aortic (v. heart disease, 
valvular), 231 
mitral, 231 
pyloric, 125 
Sterilization of food, 70 
Stomach, diseases of, 104 
Stomatitis, 96 
aphthous, 98 
etiology, 98 
symptoms, 98 
catarrhal, 97 
etiology, 97 
symptoms, 97 
treatment, 102 
gangrenous, 101 
etiology, 101 
pathology, 101 
prognosis, 102 
symptoms, 102 
treatment, 103 
parasitic, 100 
diagnosis, 101 
etiology, 100 
pathology, 100 



566 



INDEX 



Stomatitis, parasitic, 100 
symptoms, 101 
treatment, 102 
ulcerative, 99 
etiology, 99 
pathology, 99 
symptoms, 99 
treatment, 102 
Stools, examination of, 37, 38 
Stools, abnormal constituents of, 39 
bacterial examination of, 42 
normal infantile, 37 
parasites in, 157 
Starvation, 37 
Stridor, congenital, 165 
Sudden death in infants, 92 
Syphilis, 458 
acquired, 458 
congenital, 458 
hereditary, 458 
diagnosis, 462 
pathology, 459 
prognosis, 463 
symptoms, 460 
treatment, 464 
Syringomyelia, 384 



Tabes mesenterica (v. marasmus), 

422 
Tache cerebrale, 14 
Tape-worms, 159 
Tenia saginata, 159 
Tenia solium, 160 
Teeth, abnormalities, 96 

care of, 2 

Hutchinson, 96 

in rickets, 96 
Temperature, of sick room, 5 
Temperature, taking of, 22 
Tetany, 443 
Therapeutics, 24 
Throat, diseases of, 393 
Thymic death (v. status lympha- 
ticus), 92, 447 



Thymus gland, enlargement of, 92, 
447 
diagnosis, 449 
symptoms, 448 
treatment, 449 
Tinea, 279 

circinata, 281 
diagnosis, 281 
etiology, 280 
symptoms, 281 
treatment, 281 
Tinea, tonsurans, 279 
diagnosis, 280 
pathology, 279 
prognosis, 280 
symptoms, 279 
treatment, 280 
Tonsillitis, acute, 400 

cryptic (v. follicular), 401 
follicular, acute, 401 
diagnosis, 402 
symptoms, 401 
treatment, 402 
parenchymatous, acute, 403 
symptoms, 404 
treatment, 404 
rheumatic (v. rheumatism), 466 
superficial, acute, 400 

symptoms, 401 
ulcero-membranous, 403 
treatment, 403 
Tonsils, hypertrophy, 405 
etiology, 406 
symptoms, 406 
treatment, 406 
Top milk, 65 

Trousseau's symptom (v. spasmo- 
philia), 443 
Tuberculosis, 450 
diagnosis, 455 
etiology, 450 
intestinal, 426 
pathology, 457 
prognosis, 453 
symptoms, 455 



INDEX 



567 



Tuberculosis, 203 

treatment, 203 
bronchial glands, 454 
chronic, 200 
latent, 452 
lungs, 197 

lymphatic glands, 456 
fibro -caseous, 200 
miliary, 197, 456 
pulmonary, acute, 197 

diagnosis, 199 

pathology, 198 

symptoms, 198 

treatment, 200 
fibro-caseous, 202 

diagnosis, 202 

diet, 203 

prognosis, 203 

symptoms, 203 

treatment, 203 
Tuberculous adenitis (v. adenitis), 
456 
meningitis (v. meningitis), 313 
peritonitis (v. peritonitis), 162 
Typhoid fever, 505 
abortive, 513 
blood in, 512 
carrier, 505 
complications, 515 

diagnosis, 516 

diet, 519 

etiology, 507 

pathology, 507 

prognosis, 514 

relapses, 513 

symptoms, 509 

treatment, 518 
Uremia, 251 

Urinary tract, disease of, 242 
Urine, in infancy and childhood, 22 
Urticaria, 277 
diagnosis, 278 
etiology, 277 
symptoms, 277 
treatment, 278 



Vaccination, 529 

operative technique, 529 
Vaccine lymph, 529 
Vaccinia, 528 

prognosis, 531 

symptoms, 530 

treatment, 532 
Vaginitis (v. vulvo-vaginitis), 265 
Valvular heart disease, chronic, 
230 

prognosis, 233 

symptoms, 231 

treatment, 237 
Varicella, 532 

diagnosis, 534 
etiology, 532 

gangrenosa, 533 
symptoms, 533 
treatment, 534 
Variola, 525 

prognosis, 527 

symptoms, 526 

treatment, 527 
Varioloid, 525 
Vincent's angina, 403 
Vomiting, cyclic, 119 

diagnosis, 122 

symptoms, 121 

treatment, 123 
Vomiting, 105 
Vomiting, recurrent, 119 
Vulvo-vaginitis, 265 
treatment, 265 

Weaning, indications for, 46 
Weaning, false indications for, 47 
Wet nurse, 47 

Whooping cough (v. pertussis), 
534 

Widal's test (v. typhoid-fever), 
516 

Winkel's disease (v. hemoglobin- 
uria), 246 
Worms (v. parasites), 159 

Xanthroproteic reaction, 41 



